Transgender

A 40 year old transgender male to female patient establishes care with you for the first time. She says she was healthy until five years ago when she was diagnosed with hepatitis C cirrhosis. She established care at that time and is compliant with a diuretic regimen. However, she's had refractory ascites and edema. Indeed, when you examine her today, you note a tense abdomen with dullness to percussion at the flanks and a positive fluid wave. When you review labs she brought from her previous care provider, you note that she has an elevated CA-125 of 300 U/mL (normal 0-35 U/mL). There is no indication of why this test was sent.

Challenge: What's your interpretation of this test result?

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Bronze

This disease manifests at age 40 in men and later in women. Patients present with weakness, lethargy, arthralgia, impotence, diabetes, and dilated cardiomyopathy.

Challenge: What's your diagnosis?

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Struck Dumb

A previously healthy gentleman presents with sudden onset excruciating headache and diplopia. In the emergency department, he has persistent hypotension refractory to aggressive fluid resuscitation. A T1-weighted MRI is shown above.

Challenge: What's your diagnosis?

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Home Call

You are taking "home call" as a surgery resident. You're not really sure what this means until you get called by a patient who says she has "tingling in the lips and fingertips." You glance at your signout which says "s/p total thyroidectomy for thyroid cancer."

Challenge: What's your midnight diagnosis?

Image shows a rendering by Max Bro of a thyroidectomy performed by surgeon William Halsted, from www.jhu.edu, shown under Fair Use.

Not the Neck

A 30 year old G6P3 woman in her second trimester is referred to your obstetrics practice because she has a history of mid-trimester losses as well as a history of short labors. She has three living children, and during those pregnancies, she has had successively earlier deliveries. On examination, you note cervical dilation to 4cm and 80% effacement even though she is only at 22 weeks. She has no painful contractions, vaginal bleeding, ruptured membranes, or signs of infection. There's been a slight change in the color of vaginal discharge from clear to light yellow which also seems thinner, but other than that, she's asymptomatic. Her other gynecologic history is only notable for an abnormal pap smear at age 25 for which she received LEEP.

Challenge: What is your most likely diagnosis at this point?

Odds

You see a 40 year old woman in clinic who complains of pain at the bottom of her left foot. She says "I've been trying distance running and ballet to cut down on my weight." Her BMI is 30. On exam you do the following:

This elicits point tenderness. You get a screening complete blood count, basic metabolic panel, erythrocyte sedimentation rate, and C-reactive protein which are all within the normal range. X-rays are shown below (and labeled!):

Challenge: This could be many things, but what is the most likely cause?

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Hyphen

You meet this patient with a rare autosomal recessive disease. She has a history of recurrent severe bacterial infections including pyoderma, skin abscesses, and ulcerations. They are often caused by Staphylococcus, Group A Streptococcus, and Pneumococcus. Her dentist follows her for gingivitis, oral ulcerations, and periodontal disease. She has had a few episodes of respiratory tract infections as well. On review of systems, the patient reports bruising easily and abnormal musocal bleeding.

On exam, you note hepatosplenomegaly and lymphadenopathy. Unfortunately, as she gets older, her exam may show weakness, sensory deficits, peripheral neuropathy, ataxia, tremors, cranial nerve palsies, and seizures. Laboratory tests show neutropenia. Blood smear is shown below.

Challenge: What is this hyphenated diagnosis?

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Araneae

Yikes!

A boy comes in with a bite while putting on a shirt, and the spider above is the culprit. He didn't think much of it at the time since it wasn't initially painful. But over the next few hours, he started having more and more pain. He also has malaise, nausea, fever, and myalgias.

Initially, the parents describe erythema with two cutaneous puncture wounds on the skin. Over time, it developed a central pallor, and now on exam 2 days later, you note a dark, depressed eschar. It looks almost necrotic, and the area has decreased sensation.

Challenge: Identify the spider.

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Hear Hear

A patient comes to you complaining of hearing loss. He says that ever since he "caught a cold which worsened his allergies," he feels like his hearing is muffled, almost like he's under water. He can "pop" his ears and then they sound normal for a while. On exam, you see that the tympanic membrane is retracted without moving properly.

Challenge: What's your treatment of choice?

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