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You are a radiologist and get several X-rays sent by the emergency department for young men in their 20s with chief complaint "arrested by law enforcement." You sigh.

Challenge: What's your diagnosis?

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Sniff

A newborn girl presents in the first few days of life with upper airway obstruction and noisy breathing. On feeding, she becomes cyanotic, which resolves when she cries. To help, you try to place a nasal trumpet to relieve obstruction but cannot advance the 6 French catheter. An oral airway helps the obstruction until definitive surgery can occur. CT is shown below.

Challenge: What's the diagnosis?

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Tos

A 30 year old man presents with a week of cough. "It started seven days ago, and at first I thought it was a common cold, but it just didn't get better. I didn't have fever or anything, so I wasn't concerned, but soon my cough started producing this green and yellow sputum." In fact, cough in patients with this disease often lasts 10-20 days. The patient has no shortness of breath, chest pain, hemoptysis, fevers, chills or any other symptoms. He has no other medical problems, medications, or significant social history. The patient reports an up-to-date vaccination on pertussis. On exam, vitals are normal and lungs are clear to auscultation. A lateral film is shown below.

Challenge: You decline to prescribe antibiotics because the clinical presentation most likely suggests what disease caused by which organisms?

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Frog

Challenge: What is this blue, fluctuant swelling?

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Drugs II

A 25 year old man with depression attempts suicide by overdosing on the pills shown above. The pills belong to the father who has "super refractory hypertension." The father doesn't remember exactly what he takes, but says he's "on everything." The patient was found about two hours after ingestion with altered mental status and lethargy. In the ED, he is comatose. He has miosis, hyporeflexia, and hypotonia. A very painful stimulus elicits some movement. Respiratory rate is 6. Heart rate is 45. Blood pressure is 80/40. EKG shows sinus bradycardia.

Naloxone and flumazenil are administered, and no change is noted. The father says he does not take any opiates, barbiturates, or benzodiazepines. Finger stick blood glucose is normal. Blood alcohol level, serum salicylate, acetaminophen level, and standard urine toxicology are negative. CBC, chemistries, LFTs, and coags are within normal limits. CXR is clear. A head CT is negative. ABG initially shows a hypercarbic respiratory acidosis, but even after this is normalized with intubation and mechanical ventilation, no change in mental status is noted.

Challenge: The patient overdosed on one medication. What antihypertensive is the culprit here?

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Drugs I

A 50 year old woman presents with the rash shown above as well as ankle edema. She has a history of hypertension, hyperlipidemia, diabetes, Parkinson's disease, asthma, GERD, gastritis, osteoporosis, osteoarthritis, hepatitis B, gout, and anxiety disorder. Her medications are: metoprolol, lisinopril, atorvastatin, insulin (glargine and lispro), levodopa, amantadine, albuterol inhaler, ranitidine, omeprazole, vitamin D, ibuprofen, fluoxetine, glucosamine, St. John's wort, and feverfew! The culprit for the rash is shown below.

Challenge: What's the culprit?

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Toes

Challenge: The parents of this newborn (12 hours old) ask why the toes are so blue. The child was born at 36 weeks by a normal spontaneous vaginal delivery, but the mother had a prolonged rupture of membranes and is GBS positive.

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Aftermath

A woman comes to you because she hasn't been able to find a job ever since she escaped an abusive relationship.  She feels her heart race and has trouble breathing every time she meets someone named "John," the name of her ex-boyfriend. She dreams about that relationship and has disturbing memories and thoughts constantly. And yet, she does not want to talk about the relationship or what happened. She gets pretty upset when you try to tease out the details. Finally, she admits avoiding restaurants and bars they frequented together. In fact, she doesn't go out at all; she says the things she used to enjoy in the past simply don't make her happy anymore. She feels distant and cut off from people, feels emotionally numb, has trouble falling asleep, and feels easily startled.

Challenge: What's the most likely diagnosis?

List

Sorry today's case posted late. Today's case is somewhat memorization-heavy, but happens to be very practical to review.

Challenge: Name the antibiotics that can treat this much feared aerobic bug that haunts hot tubs and contact lens solutions.

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