Thursday, October 28, 2010


You are asked to consult on a newborn who is several days old and has persistent jaundice, vomiting, poor feeding, and failure to thrive. She was born at home to a 30 year old healthy G1P1 mother. They did undergo prenatal screening but the patient has not seen any doctors since birth. When you examine the patient, you note a jaundiced lethargic infant with hepatomegaly and hypotonia. The fontanelle is full, and there is some edema and possibly ascites. Two weeks later, lenticular cataracts are noted; if this is not caught early, patients with this disease develop a nuclear cataract where the nucleus of the lens looks like a cloud of dust. Laboratory tests in the infant show a hyperbilirubinemia, abnormal LFTs, coagulopathy, and increased levels of plasma phenylalanine, tyrosine, and methionine.

Challenge: What's a possible diagnosis?

Image is in the public domain.

Monday, October 25, 2010

Milk of Amnesia

You are a newly minted anesthesia resident and are called to assist in the anesthesia of a patient undergoing a painful reduction of a fracture (there is a fracture, I must fix it). You did an induction at the beginning of your shift 12 hours ago and still have half a bottle of propofol in your pocket. You go ahead and use it to induce anesthesia, and there are no problems. The orthopedic surgeon is happy, and you go on your way. A couple hours later, a rapid response team is called and you rush to the bedside to find that it is the very same patient. He's febrile, tachycardic, hypotensive, and tachypneic. He is diaphoretic with bounding pulses.

Challenge: What happened?

Image is in the public domain, from Wikipedia

Thursday, October 21, 2010

There is a Fracture, I Must Fix It

This gentleman had a sports accident where he fell onto his shoulder.

Challenge: Where is the fracture?

Image shown under Fair Use.

Monday, October 18, 2010


Both EKGs above are from the same patient, a 70 year old man with many medical comorbidities. He initially presented to the clinic for lightheadedness, presyncope, and palpitations. He switches into and out of the rhythms shown above.

Challenge: What is the syndrome described here?

Both EKGs shown under Creative Commons Attribution Share-Alike 3.0 License.

Thursday, October 14, 2010

Scar (Not Eschar)

This is a particularly challenging case. The images above are from a patient who noted acute onset nonpitting edema of the arm. This later became a symmetric induration with puckering, giving the irregular, woody texture of the skin of an orange peel. The disease spares the hands and feet. When you raise the affected limb, visible indentations appear along the course of the superficial veins. The patient also complains of arthritis. Labs surprise you with an eosinophilia.

Challenge: What is your diagnosis?

Both images shown under Fair Use.

Monday, October 11, 2010


This child who had a recent ED visit for acute sinusitis presents with swelling and erythema around her eye. Eye movements are painful. You note chemosis, proptosis, and mild globe displacement on exam. It is difficult to test visual acuity since she complains about seeing double. She refuses extraocular movement testing.

Challenge: What's the diagnosis and what are the bugs?

Image shown under Fair Use.

Thursday, October 7, 2010


Challenge: A simple question but: what is the device shown here and where are its leads?

Image shown under Fair Use.

Monday, October 4, 2010


Challenge: Diagnosis?

Image shown under Fair Use.