Teardrop

This finding is seen in a construction worker who had acute vision loss at work. On exam, you note that this pupil constricts when light is shined on the opposite eye, but there is less constriction when light is shined on the affected eye. When fluorescin is placed, you note this (they are different pictures, but imagine the top of the green to be the top of the teardrop pupil):

Challenge: Where's the injury? What happened?

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Masquerade

This woman comes in with patchy light to dark brown hyperpigmentation of the cheeks, forehead, and upper lip. This condition is more commonly seen in Asians, African Americans, and Hispanics. It is related to sun-exposure.

Challenge: This common condition affects 75% of women who are...what?

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Reverse Engineering

You are screening antibiotic requests and note that a young adolescent is being treated with a single injection of 250mg ceftriaxone along with doxycycline 100mg BID for seven days.

Challenge: What's one possible infection this could be targeted at?

Memento

A 60 year old man with an insignificant past medical history presents with sudden onset of confusion. His wife witnessed him and said he was disoriented to time and repetitively asked questions about the date and the place, sounding almost like a broken record. His wife, a psychologist, tested digit-span and the patient was able to repeat a 7-digit number immediately, but delayed recall was impaired. He also had some amnesia of recent events of the last few days. Oddly enough, the patient was able to continue cooking and afterward, he played piano perfectly. He had no garbled speech, no facial droop, no weakness, and no focal or lateralizing signs. After six hours, the patient recovers completely. He can't recall what happened during those six hours. He had no other complaints. You see him in the emergency department after the entire episode has resolved, and your physical exam is perfectly normal. Labs are all normal. EKG is normal sinus rhythm.

Challenge: What's your most likely diagnosis?

Vienna

In 1881, Sir William Osler, MD, CM, 1st Baronet, described this clinical triad: An African American patient looking about 60 years old is brought in from the streets with altered mental status. He looks sick. In his pockets, he has a couple packs of cigarettes, a bottle of Vodka, insulin syringes, and crack cocaine (he has really large pockets). He is febrile, tachycardic, hypotensive. On exam, he is altered, not answering appropriately; pupils are sluggish, he has no focal neurologic deficits, but he does have nuchal rigidity.

On pulmonary exam, you hear decreased breath sounds at the right base. A chest X-ray is shown below:

On cardiac exam, you note a systolic murmur at the right upper sternal border. The echo tech is rolling the machine by so you grab it and take a look:


The abdominal exam is remarkable only for a LUQ scar. The extremities are normal. A rectal exam is normal. Here are the blood cultures:


Challenge: Name three disease processes occurring here. Name the organism. There's your triad.

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Taurus

This rash is seen on the back of the neck of an eighty year old woman who has HTN, DM, dyslipidemia, COPD, arthritis, urinary incontinence, GERD, and migraines. Her medication list spans two pages. Lesions are noted in flexural areas, the groin, the axillae, and the mouth. They are itchy. A diagnostic procedure is done and results are shown below:

Challenge: What's your most likely diagnosis?

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Picture Perfect

Oh, there were so many responses to the last few cases, this might ruin that.

A 75 year old African American gentleman with a positive family history of this disease comes to his usual annual eye appointment. He has no symptoms; no pain, redness, halos, or other eye problems. He's not aware of any vision loss, though exam shows:

His vision is as follows:Challenge: What is the most likely diagnosis?

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Appendages

A 40 year old woman presents to the emergency department with acute onset abdominal pain along with waves of nausea and vomiting. The pain is in the lower abdomen, stabbing in quality, radiating to the back, flanks, and groin. There is no fever and no peritoneal signs. The patient says she was just exercising vigorously when the pain occurred. Pregnancy test is negative.

The patient is taken to laparoscopy. The intestines including the appendix appears normal. But this is seen:

Challenge: What is that? What's the diagnosis?

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