Desserts

A 60 year old man with atrial fibrillation, cirrhosis, adrenal insufficiency, and coronary artery disease presents with a severe pneumonia. He is intubated for hypoxemic respiratory failure and admitted to the intensive care unit. His blood pressure is 100/40, heart rate 110, and temp 101. Early goal directed therapy is initiated, and he is bolused 5L crystalloid and started on norepinephrine. His ventilator settings are tidal volumes 400, rate 16, PEEP 5, PS 10, FiO2 50% with SpO2 96%. His CXR shows a multilobar consolidation. His coumadin, propranolol, and ASA are held. Labs show WBC 20,000, hematocrit 12, platelets 40,000, creatinine 1.0, and INR 2.8. His current medication list is: dexmedetomidine drip, hydromorphone drip, norepinephrine drip, albuterol/ipratropium, hydrocortisone, vancomycin, piperacillin-tazobactam, levofloxacin, insulin as needed, lactulose, and subcutaneous heparin. He is kept NPO. On hospital day 3, he drops his hematocrit to 9. An upper endoscopy shows shallow mucosal oozing in the fundus and body of the stomach.

Challenge: What's the diagnosis?

Risk Factors

A 60 year old patient with diabetes, COPD, AML s/p chemotherapy with ongoing neutropenia, history of cholecystectomy, and inguinal hernia presents with a COPD exacerbation. He is treated with nebulizers, high dose steroids, and broad spectrum antibiotics. He slowly improves, but then develops a small bowel obstruction. The surgeons recommend nonoperative management; an NG tube is placed. Because he is slow to improve, a PICC line is ordered and total parenteral nutrition is started. On hospital day 7, he becomes febrile, hypotensive, and tachycardic. He complains of chills and blurry vision. His antibiotics are broadened to cover extended spectrum beta lactamase organisms. He continues to deteriorate clinically.

Fundoscopic exam is shown below:

Challenge: What are you worried about?

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Tiny

A preterm newborn at 34 weeks with meconium aspiration syndrome presents with tachypnea, grunting, mild pallor, and cyanosis. When you glance at the monitor, you note that the QRS voltages are pretty small.

Challenge: What's your diagnosis?

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Crazy

An African American woman initially presents with headache, fever, and "flu-like symptoms." She takes a few days off work, but then starts to develop odd psychiatric symptoms. She has new anxiety, agitation, and bizarre behavior. Her husband thinks she's hallucinating and has delusions. She has gaps in her memory, cannot sleep, and develops strange orofacial dyskinesias. Over the ensuing few days, she has a seizure, becomes mute, and develops stupor with catatonic features. Vital signs show hyperthermia and inconsistent blood pressures and heart rates; over the hospitalization, she has hypertension, hypotension, tachycardia, and bradycardia. Neuro exam shows dystonia and rigidity. CSF shows lymphocytic pleocytosis. EEG shows slow, disorganized activity that does not correlate with abnormal movements. Brain MRI is normal. CT of the abdomen and pelvis is shown below:

Challenge: The diagnosis is made on detecting antibodies to the receptor shown above. What is it?

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Writing

Challenge: This started 6-7 minutes after the inciting factor and will fade in 15-30 minutes. What is it?

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Steal from the Rich

This child often has airway obstruction from his tongue flopping back into his mouth. He also has trouble feeding. You recommend placing him in the prone position and using a nasopharyngeal trumpet to help his breathing until he gets bigger.

Challenge: What's the diagnosis?

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Thought I Fixed It

A patient presents with shortness of breath and an X-ray shown above. His hemodynamics are stable. You recognize the diagnosis and heroically perform a procedure under local anesthesia to correct the pathology. You pat yourself on the back, order an X-ray, and go back to the call room.

Unfortunately, the repeat X-ray is shown below.

The patient has severe cough, dyspnea, and hypoxemia.

Challenge: What happened?

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Egg

Challenge: This is the first structure to appear within the gestational sac and confirms an intrauterine pregnancy. It can be seen at the 5th week of gestation. What is it?

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Socrates

A patient is brought into the emergency department with tonic-clonic seizures. A friend says, "We found some wild vegetables...we thought it was parsley or turnip or carrots or something." She brings in the plant shown above. "He ate a little," she says, "and before he started seizing, he had nausea, vomiting, and abdominal pain. Then he started acting a little confused. When I touched him, he was drenched in sweat." Vital signs show bradycardia and hypotension. Despite initial antiepileptic therapy, he remains in status epilepticus; these seizures are fairly intractable.

Challenge: What is this poisonous plant which acts by GABA antagonism?

Image is in the public domain.