Thursday, March 31, 2011


You are doing telemedicine and get these pictures from patients in Turkey. Patients are 20-40 years old and have recurrent painful lesions shown above. HSV is negative. They tend to be extensive and patients can have multiple lesions. For some patients, the pain is so bad they can barely eat anything. Yet the ulcers heal by themselves within 1-3 weeks.

Some patients get genital HSV screening too because they complain about the same lesions on the scrotum and vulva; often, these even lead to scarring. When doing a thorough skin exam, there are many varied lesions which can be acneiform, papulo-vesiculo-pustular, pseudofolliculitis, nodules, erythema nodosum, superficial thrombophlebitis, pyoderma gangrenosum, erythema multiforme, and palpable purpura. If you prick the skin with a needle, a pustule-like lesion or papule may form.

Eye abnormalities are also common, involving bilateral episodic uveitis, occasionally with purulence in the anterior chamber. Rarely, neurologic involvement may cause focal deficits. Some people present with hemoptysis. Others have recurrent DVTs. Most patients have a nonerosive asymmetric nondeforming arthritis of the knees, ankles, and wrists.

Challenge: What's your diagnosis?

Image shown under Fair Use.

Monday, March 28, 2011

Current Events

You are participating in international relief efforts abroad as a result of natural disasters. Patients come in with multiple exposures. Those who've been exposed within several hours present with anorexia, apathy, nausea, vomiting, diarrhea, fever, tachycardia, and headache. Some people die immediately from fever, hypotension, coma, and severe vomiting. Others present with neurologic deficits and have disorientation, confusion, loss of balance, seizures, papilledema, ataxia, and decreased reflexes.

Those who were exposed 5 days ago have crampy abdominal pain, diarrhea, nausea, vomiting, and GI bleed. In weeks to months, patients expect neutropenia, thrombocytopenia, and anemia.

Challenge: What was the exposure?

Image is in the public domain.

Thursday, March 24, 2011


The cases get harder!
These images are from children under the age of 5 with symmetric sudden eruptions of raised lesions, mostly on the cheeks, buttocks, and extensor surfaces of forearms and legs. The lesions were preceded by an upper respiratory or gastrointestinal illness. The lesions do not go away and last for weeks. Itchiness varies. Some patients have lymphadenopathy; some have elevated liver function enzymes. The lesions usually spontaneously resolve after weeks.

Challenge: What's your diagnosis?

First image is in the public domain. Other three images shown under Fair Use.

Monday, March 21, 2011

Taking A Day Off

I'm taking a quick break today from a new case as things have been incredibly busy. I'll be back with a new case on Thursday. Meanwhile, I wanted to direct you to The Atrium Magazine, a new, innovative web-based resource created by a friend of mine at Yale University. My cases of the day are actually featured here:

Thursday, March 17, 2011

Mickey Mouse

Challenge: This pattern of findings is consistent with what kind of disease?

Images shown under Fair Use.

Monday, March 14, 2011

Fowl Play

You are the anesthesiologist for a neurosurgery for a patient with cranial synostosis. The patient is in Fowler's position. You DJ the iPad music, glance at the news of the day, and listen to blips of the heart (you can YouTube this). Suddenly the patient becomes immediately hypotensive and tachycardic. You note the patient's JVP suddenly rises. You turn down the music and hear a sucking noise. You send a stat ABG from the radial art line which showed hypoxemia and hypercarbia. The EKG on the monitor shows peaked p waves, non-specific ST changes, and sinus tachycardia. You start fluids wide open, prepare vasopressor support, and ask the neurosurgeon to place the patient into Tredelenberg.

Challenge: What happened?

Image from, shown under Fair Use.

Thursday, March 10, 2011

The Mean Folk

This adolescent woman has tried multiple topical therapies without relief and wants to switch to a systemic therapy. Your preceptor asks you to counsel her on safe sexual practices.

Challenge: Why?

Image shown under Fair Use.

Monday, March 7, 2011


An older gentleman comes in with a productive cough and shortness of breath. By nursing protocol, he gets an EKG, shown above. You make a clinical diagnosis of community acquired pneumonia and write a prescription for moxifloxacin. There are no TB risk factors. Your attending, aghast, says that's not appropriate!

Challenge: Why?

Image shown under Fair Use.

P.S. Sorry, I was late with this post as I accidentally put it on my regular blog.

Thursday, March 3, 2011

Suicidal Ideation

A 25 year old man is brought in by EMS. A suicide note and an empty unlabeled bottle are found next to him. The patient is minimally arousable, hyperthermic, and flushed. Pupils are dilated. Minimal bowel sounds are heard. A Foley catheter is placed and 400cc urine comes out. Fingerstick glucose, acetaminophen, and salicylate levels are fine. Here's an EKG:

You recognize what's going on and push sodium bicarbonate. The EKG changes before your eyes to:
Challenge: What happened?

Images are shown under Fair Use.