Dehydrated

A farmer presents with the chief complaint, "I have fluids gushing out of every orifice." Ew. He has nausea, vomiting, diarrhea, urinary incontinence, sweating, lacrimation, and salivation. On exam, you note bradycardia with a heart rate of 42, miosis, and wheezing. On review of systems, the patient has some subjective muscle weakness. EKG shows heart block and QT prolongation. Atropine 1mg IV is administered with little effect on the heart rate.

The patient is admitted to the hospital. Due to the fascinating findings, both neurology and internal medicine want to be the primary service. About 24-96 hours later, the patient develops neck flexion weakness, decreased deep tendon reflexes, cranial nerve abnormalities, proximal muscle weakness, and respiratory insufficiency. Now, neither internal medicine nor neurology wants the patient so he goes to ICU. After two weeks in the ICU including a stint on the mechanical ventilator, the patient has complete resolution of his neurologic symptoms.

Challenge: What's your diagnosis?

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Rock, Paper, Scissors

You are about to perform a radial arterial line for continuous hemodynamic monitoring as well as multiple ABGs when your senior resident says: "Wait, did you perform the test?"

Challenge: Few people do it, but it's the proper thing to do. What test?

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Ear All About It!

This older patient (or unimmunized adolescent) presents with left-sided facial paralysis and ear pain. He complains that things taste and sound differently; he has a buzzing in his ear and everything's louder. He also has vertigo. Prior to the onset of the rash shown above, he noted burning pain, hyperesthesia, and pruritis.

Challenge: What's your diagnosis?

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Jailbreak

This patient has had surgery for endometriosis in the past as well as a history of pelvic inflammatory disease. She presented, however, at 14 weeks gestation with abdominal and back pain as well as urinary retention, frequency, and the sensation of incomplete emptying. Symptoms started a few weeks prior, but resolved, and now have returned. She has no vaginal bleeding, discharge, or contractions. Pelvic exam shows anterior displacement of the cervix behind the symphysis pubis; the cervix cannot be visualized and the external os is not palpable. There is a large mass in the cul-de-sac and the uterus is difficult to palpate on bimanual exam. Ultrasound done at 16 weeks confirms the diagnosis and an intervention is planned.

Challenge: What's the diagnosis?

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Always Put This On Your Differential

A 40 year old woman presents with a right facial droop, initially thought to be Bell's palsy until she develops a left sided one subsequently. She presents to her primary care doctor who does a review of systems and finds polyuria as well as disturbances in thirst, sleep, appetite, and libido. Not much is done, and she is told to follow up in a few months. In the meantime, she has a partial seizure and returns to the hospital. A contrast-enhanced MRI shows nonspecific meningeal enhancement and multiple white matter lesions. A lumbar puncture shows a mononuclear cell pleocystosis and elevated total protein. Glucose is normal. A CT of the chest is obtained due to an abnormal routine chest X-ray and is shown below.

Challenge: What's your diagnosis?

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Basilisk

A 20 year old patient comes in with acute abdominal pain, anorexia, nausea, and vomiting. The pain started at the bellybutton, then migrated to the right lower quadrant. Exam shows fever and tachycardia. The point of maximal tenderness is 1.5 inches from the anterior superior iliac spine on a straight line from the ASIS to the umbilicus.

Challenge 1: What's this point called?

Palpation of the left lower quadrant causes pain in the right lower quadrant.

Challenge 2: What's this sign called?

The diagnosis is confirmed. The patient is brought to the operating room where standard monitors are placed and he is pre-oxygenated. A rapid sequence induction is performed with cricoid pressure. A total of 2mg midazolam, 150mcg fentanyl, 150mg propofol, and 100mg succinylcholine is administered. He is an easy intubation. A peripheral nerve stimulator is used to see when he regains neuromuscular function; however, no twitches come back. In fact, the whole operation is performed without any additional neuromuscular blockade. At the end of the surgery, the patient remains paralyzed and does not spontaneously ventilate. He is brought to the ICU. Six hours after induction, he begins to regain muscle function. He has an uneventful discharge two days later.

Challenge 3: You've done 3200 cases where this hasn't happened. What's the diagnosis? (ie. the prevalence of this disease is 1/3200).

25% of the World Has This

An immigrant from Southeast Asia brings his six year old child to the doctor because of loose stools with some mucus and blood, especially at night. A CBC with differential shows a mild anemia with peripheral eosinophilia (15%). Exam shows rectal prolapse. The patient is at the lower end of normal with regards to growth and cognition. This is seen in the stool:

Challenge: What's your diagnosis?

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Coffee Grounds

A 40 year old man with peptic ulcer disease, arthritis, and chronic low back pain presents with coffee ground emesis that began several hours ago. He takes only naproxen for his joint pain. He has a mild smoking and drinking history. His vital signs are: T 37.8, HR 95, BP 120/60, RR 14, SpO2 97%. His abdomen is diffusely tender.

You place a nasogastric tube and do an NG lavage but no blood or coffee grounds comes back. Instead, the patient becomes acutely agitated, tachypneic, and hypoxic. Vital signs are T 37.6, HR 110, BP 130/70, RR 20, SpO2 90%. You get a chest X-ray, shown below.

Challenge: What happened?

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pH

A 25 year old woman with diabetes and recurrent UTIs presents with dysuria. Initially, she thinks this is her usual UTI, but then she starts having vulvar pruritis, soreness, irritation, and dyspareunia. There is no discharge. She decided to go see her regular doctor (that's you!). Her medications are nitrofurantoin and an oral contraceptive. Examination shows vulvar erythema and edema. There is some thick, adherent, cottage-cheese-like discharge. The vaginal pH is 4. You make your diagnosis.

Challenge: What is it?

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