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Parents bring in their 1.5 year old infant for the fifth time this year because of recurring fevers. "It seems like every month for 2 or 3 days, our child doesn't feel well," they say. "I think I had it," the dad says, "and my dad too, and my sister, and my aunt. My sister actually died of a clostridium infection when she was a child." You look into the patient's past medical record, and 3 weeks ago, the child presented with pharyngitis, and 3 weeks before that, with a bacterial skin infection, and 3 weeks before that, malaise, and 3 weeks before that, gingivitis.

On exam, you notice significant gingival disease and chronic mouth ulcers. The child looks otherwise normal, with a normal growth curve, no dysmorphic features, and no hepatosplenomegaly. Labs are surprising. At each visit, the child's ANC (absolute neutrophil count) is around 200-400. But labs drawn at "well-child visits" when he is not sick show a normal CBC.

Challenge: What's your diagnosis?

Young Woman with Abdominal Pain

A 30 year old woman presents with abdominal pain, your favorite chief complaint for that demographic. The pain is in the epigastric and RUQ areas. You note hepatomegaly with no Murphy's sign. Her urinary pregnancy test is negative; she protests, "I take my oral contraceptive religiously, like I have for the last fifteen years." You find that she's visited her primary care doctor multiple times with no diagnosis. Finally, you succumb to CT scan.

Whoa! You did not expect to see that. This CT shows a large complex enhancing mass of the left lobe of the liver with displaced vessels (small arrowheads). A smaller low attenuation mass is also noted in the right lobe of the liver.

While coming out of the CT scanner, she screams in pain and collapses. Her blood pressure is 60/palp. You start resuscitating her aggressively and the surgeons take her to the OR immediately. They find gross blood in the peritoneum.

Challenge: By textbook, this lesion is usually solitary in the right lobe of the liver, but this patient's history makes her prone to more complex lesions such as this one. What's the most likely diagnosis?

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Territorial

Challenge: Localize the lesion.

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Gem

Sorry about the late post today!
These ghoulish crystals are seen in an alkaline urine of a patient with dysuria.

Challenge: What organism(s) do you expect?

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Belly

This gentleman with longstanding hepatitis C, hypertension, and diabetes presents with a temperature of 100.4 F (38 C) and mild abdominal tenderness. His wife says that he's been a little confused lately. Labs show a leukocytosis, azotemia, albumin of 2. You put in a needle and take out fluid from the belly. These fluid studies show:
Albumin 0.2
Total protein 0.5
Glucose 80
WBC 600
RBC 2500
45 % neutrophils
40% lymphocytes
15% monocytes

Challenge: What's your diagnosis?

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Next Step

Yes, I've shown a similar EKG before, but I had to write this case last minute. A 70 year old man who has never seen a doctor before presents with chest pain and the EKG shown above.

Challenge: What's your next step in management?

Image is in the public domain.

Sorry!

Hi everyone! I apologize - no case today mostly because I haven't had time to put one together. I shall try to have a case ready by tomorrow morning, solution on Monday. Thanks! -Craig

Common Welsh Surname

Both images show the same finding in a young athlete who describes acute onset pain on the lateral side of his foot, anterior to the ankle. He was playing basketball at the time. He has difficulty bearing weight. Examination shows edema and ecchymosis.

First image shown under GNU Free Documentation License; second image shown under Creative Commons Attribution Share-Alike License.

Tic-Tac-Toe II

This is part two of a two part case. Please scroll down to see the first part.

The 70 year old gentleman presents to clinic several months later with recurrent urinary tract infections. He also says he has a weird symptom: when he urinates, he sometimes pees air. Physical exam is unremarkable.

Challenge: What?

Tic-Tac-Toe I

This is the first part of a two-part case.

A 70 year old man presents with left lower quadrant abdominal pain of several days. He's had this in the past but previous episodes were mild and he's always ignored the symptoms. This time, though, he also has nausea, vomiting, and constipation. The patient has left lower quadrant tenderness with a palpable mass and abdominal distention. He has a mild fever and leukocytosis. LFTs and amylase are normal.

Challenge: This patient is not Asian. If he were Asian, how might the symptoms differ?

Image is in the public domain.