Lemon

Happy Halloween!

A young man presents with early systemic manifestations of a curious disease occurring one to two months after its initial onset. He comes to the medical system because of palpitations. You take an EKG and note something very peculiar. He goes from first degree AV block to second degree AV block to complete heart block to first degree AV block over the course of minutes. The patient works at a national park.

Challenge: A lot of clues in this case point to what disease?

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Diagnostic Arrow Sign

A 60 year old man with Crohn's disease undergoes a colonic and low anterior resection that is uncomplicated. He shows up to his follow-up appointment 6 days later and complains of low grade fever, prolonged ileus, moderate pain, and feculent drainage. Exam shows a mild tachycardia. Imaging is shown above.

Challenge: What's your diagnosis?

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Ancient History

This image is from a ward in 1918, filled with patients with the same disease. This disease typically presents with abrupt onset of fever, headache, muscle ache, malaise, cough, sore throat, and rhinorrhea. Exam shows hyperemic mucosa and mild cervical lymphadenopathy, but little else. Complications include persistent high fever, dyspnea, bilateral reticular or reticulonodular opacities, secondary infection, rhabdomyolysis, encephalitis, transverse myelitis, aseptic meningitis, and Guillain-Barre syndrome.

Challenge: What is the molecular mechanism by which such pandemics occur?

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Hurricane II

This is the second part of a two-part case; please see the prior post.

You confirm your diagnosis and begin treatment which is shown above (given as an IV bolus of 1-2mg/kg over 5 minutes). The patient does not get better after a few hours. In fact, he seems to get worse; he's more dyspneic. You decide to send another panel of labs, and when they come back, you note that the hemoglobin has dropped 3 points and the blood smear shows:

Challenge: What happened?

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Hurricane I

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

You are on call covering a whole hospital of medicine patients when you get a call from a nurse that a patient who recently had an upper endoscopy has a sore throat. The patient is a 50 year old African American gentleman with hypertension and alcohol abuse who presented with coffee ground emesis. His EGD was negative. The plan on the sign out is to discharge him the following day. His labs look fine. You decide to write him for benzocaine 20% topical throat spray and his symptoms resolve.

Once the floor quiets down, you go to sleep, and at midnight, the nurse pages you and says the patient now has a headache, fatigue, and lethargy. You figure he's just not sleeping so you give him acetaminophen and zolpidem. You go back to bed.

At 3am, a code blue is called and you rush down to find...this patient. The code blue was called for respiratory depression and hypoxia. You note an oxygen saturation of 86% and the patient is minimally arousable. You go ahead and get an arterial blood gas, shown in the image. The patient's ABG is the tube on the left; a control ABG is on the right.

Challenge: The results of the ABG are pending, but your initial diagnosis is...what?

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Worth Your Salt

Challenge: Worldwide, what is the most common cause of this condition?

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Ambiguous

You deliver an infant who has ambiguous genitalia. The child is born at 38 weeks to a 32 year old G1P1 Caucasian woman. The parent declined all prenatal screening and testing. At birth, a karyotype is 46,XX. You note clitoral enlargement, labial fusion, and formation of a urogenital sinus. She is at risk for early puberty and short stature.

Challenge: What is this autosomal recessive disorder?

Split Spine

I apologize - this case was meant to be posted in the morning.

This child, shown on her back, was born to a mother who had prenatal AFP screening that was positive. The child has bowel and bladder incontinence and does not seem to move his feet.

Challenge: What's your diagnosis?

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Cherry

A middle-aged patient presents with these on the trunk. They bleed profusely if cut. They blanch with pressure.

Challenge: What's your diagnosis?

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