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A 30 year old G1P0 has division of a single fertilized oocyte at 10 days post fertilization. Ultrasound in the first trimester shows twins, a single placental disk, and no intertwin membrane. Instillation of dye in the amniotic sac of one twin is performed and amniotic fluid drawn from near the second twin has dye.


She is admitted at 26 weeks pregnancy and will stay as an inpatient until 32 weeks when she will get a C-section. When you ask why, the attending says, "We have to do daily fetal monitoring, look for cord knots on ultrasound, and check Doppler velocitometry."


Challenge: What is the concern, which is unique to this type of pregnancy?


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Skin II

A family practitioner refers a 20 year old patient to your surgical practice. She says that this lesion grew rapidly over one to two weeks. It bleeds easily. Because this does not spontaneously regress, surgical treatment is often required. You also ask if she is pregnant since that is a risk factor for developing this.


Challenge: What is it?


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Skin I

Two skin lesions this week. Here's the first:

A farmer who works with sheep and goats presents with the lesion above. He notes fever, and exam shows regional lymphadenopathy. The lesion began as a red, solid, elevated papule then enlarged to the current state. Soon, it will form a red weeping surface, then develop a thin, dry crust with black dots covering the surface. After that, small papillomas will form. Finally, a thick crust grows over the lesion, the papillomas decrease in size, and the lesion flattens out.

Challenge: What's the cause of this disease?

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Ick

A family medicine doctor refers this 50 year old woman to your surgical practice for evaluation. Application of 5% acetic acid solution turns the lesions white.

Challenge: This is caused by a double stranded DNA virus. What's your diagnosis?

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Too Much Jowling

A 30 year old woman presents with left sided facial pain over the lower cheek. It radiates a little to the jaw and ear. It feels like a dull ache, worse with chewing. The patient is undergoing some psychosocial stressors including changing jobs and a death of a family member. Her partner says she sometimes grinds her teeth in her sleep. Palpating over the angle of the mandible leads to moderate pain on the left side. There is some tenderness over the temporal muscle on the left side as well. The last set of dental X-rays were normal.

Challenge: What's the diagnosis?

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Bean

It is May. Twelve hours after accidental ingestion of the substance shown above, a 4 year old boy complains of fever, chills, headache, nausea, and back pain. His skin turns yellow and his urine becomes dark.

Challenge: What's the diagnosis?

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Shear

This patient was involved in a motor vehicle accident. He is in a deep coma and ICP is normal.

Challenge: What kind of injury is shown here?

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Ultrasound

Challenge: What do these ultrasounds show?

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Noncardiac

A 25 year old previously healthy man who smokes presents with acute onset dyspnea and pleuritic chest pain. This was unprovoked and occurred at rest. EKG is shown above.

Challenge: What is this noncardiac diagnosis?

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