Wednesday, March 31, 2010


A hair pull test shows fragmented hairs of varying lengths.

Challenge: What is the cause of this patient's hair loss?

Image shown under Fair Use.

Monday, March 29, 2010


A 22 year old man is brought to the doctor by his roommate. The roommate has known the patient for years, but says about a year ago, the patient started acting weirder without any trigger. The patient would have episodes of not leaving his room, not talking, not responding, and not wanting to do anything. There have been 1-2 past episodes. About a week ago, the patient started acting in the same way. Indeed, the patient has a blank look on his face, responds to few verbal commands, but withdraws to noxious stimuli. The patient has no interest in his environment. He gives monotonous one-word responses to some questions. He displays no emotional range, and when asked, says he feels "bad." The roommate says the patient dropped out of community college a few months ago, has never held a job for longer than a month, and has almost no friends. Mental status exam shows poor attention, language, memory, and executive function. When you raise his left arm over his head and let go, he keeps it there even though the position is awkward. Yet when you move him in other ways, he seems to have purposeless resistance.

Challenge: What's the most likely diagnosis here?

Friday, March 26, 2010


This is a 3 year old boy with a history of nephrolithiasis who bites himself; his lower lip is mutilated and he has a wound on the dorsum of his hand. His tongue is spared. He has uncontrolled motor movements with action dystonia and baseline hypotonia. He also has delayed developmental milestones and mental retardation. Labs show a macrocytic anemia.

Challenge: What is this disorder? How is it inherited?

Image shown under Fair Use.

Wednesday, March 24, 2010

No History

You are on your radiology elective and this chest X-ray is given to you. The clinical history box reads: "Patient in ED Bed 3. Have a nice day! -Craig."

Challenge: What's the finding? What's the likely clinical scenario?

Image shown under Fair Use.

Monday, March 22, 2010

Blue Devils

A 60 year old man with diabetes complicated by dialysis-dependent renal failure, mitral valve prolapse, benign prostatic hyperplasia, and dyslipidemia presents with fever, chills, night sweats, and a rash. Unfortunately, he can't give a really good history.

His temperature is 38.5 C, his blood pressure is 125/80, his pulse is 85, and his respiratory rate is 16. Physical exam findings are shown above. The second image shows painful nodules. The third image shows painless macules. Two separate blood cultures are positive, but the lab has not been able to determine the organism yet.

Challenge: What are the likely organisms?

Related Questions:
1. What does each image show?
2. What's the diagnosis?

All three images shown under Fair Use.

Friday, March 19, 2010


You are on a medical mission in Africa where you take care of numerous children like the ones shown above. Height and weight are nearly normal for age. They all have anorexia, a palpable liver, pitting edema, hair that falls out, and dry atrophic peeling skin.

Challenge: What is your diagnosis?

Both images are in the public domain.

Wednesday, March 17, 2010

Happy St. Patrick's Day

A 60 year old man presents with a gradual onset of difficulty walking which has worsened over the last few weeks to months. He feels weak, unsteady, and uncoordinated in his legs. He's also recently developed poor coordination of the arms, dysarthria, and intermittent diplopia and blurred vision. His past medical history is only significant for a few episodes of alcoholic hepatitis and a remote appendectomy. His social history is significant for being a heavy drinker for 25+ years.

On exam, he appears malnourished. Mental status and cognitive function are normal. On his cranial nerve exam, visual fields and acuity are intact, fundoscopic exam is normal, pupils are round and reactive to light, extraocular movements are intact, facial sensation is intact, muscles of mastication and muscles of facial expression are symmetric and strong, hearing is grossly intact, palate is midline and moves fully, head rotation and shoulder shrug are strong, and tongue movement is symmetric. He has slow, slurred speech and a coarse rhythmic 3-5 Hz postural tremor of the fingers. He has ataxia of stance and gait. He cannot do tandem walking. Heel-knee-shin testing is grossly abnormal, and finger-nose testing is mildly abnormal. His blood alcohol level is 0.

Administration of thiamine does not reverse this disease.

Challenge: Localize the lesion! What's your diagnosis?

Image is shown under GNU Free Documentation License, from Wikipedia.

Monday, March 15, 2010


A 25 year old woman who is 10 weeks pregnant presents with fatigue, nausea, vomiting, and nocturia. These have all had gradual onset over the last few weeks. Her primary care doctor sends off a battery of labs and finds that serum TSH is low, serum total T4 and T3 are both elevated, and free T3 and T4 are at the high end of normal.

Challenge: What is the most likely cause of these findings?

Friday, March 12, 2010


This patient came in with a GCS of 7. His chest X ray on arrival was normal. The emergency room physicians fussed around with him a bit, and now he looks like this.

Challenge: What's the cause?

Image is shown under Fair Use.

Wednesday, March 10, 2010

Black and White

Challenge: Anatomically, where is the abnormality in this PA CXR?

Image shown under Fair Use.

Monday, March 8, 2010

Deep End

Since I'm on radiology, this week will be x-ray week.

This patient was brought into the emergency department due to trauma.

Challenge: What's the diagnosis? What kind of trauma did the patient sustain?

Image shown under Fair Use.

Friday, March 5, 2010


A 25 year old man swimming off the coast of Northern Australia feels a sharp mildly painful sting. He returns to shore, and 30 minutes later, begins to feel severe generalized back, chest, and abdominal pain, nausea, vomiting, sweating, and agitation. Physical exam shows hypertension and tachycardia. About 12 hours later, he develops myocardial injury and pulmonary edema. The tiny jellyfish shown above, about 2cm in diameter with long tentacles, was identified as the culprit.

Challenge: This syndrome has a particular name; what is it?

Image is shown under Fair Use.

Wednesday, March 3, 2010

700,000 Surgeries/Year

This image from a 40 year old man shows a shaved surgical site at the location of the pathology. He initially presented with heaviness or dull discomfort in his pelvis worse with straining, lifting, and prolonged standing. This is relieved by lying down. He noticed this bulge in the right groin, and it is more pronounced with coughing.

Challenge: What is the diagnosis?

Image is in the public domain.

Monday, March 1, 2010


I have a friend with these symptoms!

A 25 year old woman presents to your primary care clinic with foot pain while running. Normally, she is asymptomatic, but when she runs, she feels numbness, tingling, aching, and burning of the distal forefoot. The pain radiates from the metatarsal heads to the third and fourth toes. The symptoms are worse while running on hard surfaces and while wearing tight high-heeled shoes. On physical exam, you note tenderness in the plantar foot over the point noted in the diagram above. Compressing that area creates a "click" and reproduces the patient's symptoms.

Challenge: What's the diagnosis?

Image shown under Fair Use.