Nourishment Barrier

A 49 year old male farmer has been bothered for years by a migratory arthralgia of the large joints. More recently, he's developed diarrhea, weight loss, abdominal pain, and severe wasting. His family has noted that he's been more confused as well. But most recently, he's developed a curious continuous rhythmic movement of eye convergence with concurrent contractions of the muscles of mastication. On exam, he has a vertical gaze palsy and a cerebellar ataxia. Labs rule out thyroid disease, connective tissue disease, inflammatory bowel disease, and HIV/AIDS. Labs show an elevated INR.

The patient undergoes endoscopy with small bowel biopsy, shown below.

Challenge: What's your diagnosis?

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Bates

A 20 year old G1P1 woman presents two weeks postpartum with bizarre behavior. According to the husband, she has not been sleeping at all and has started "hearing and seeing things." She also believes her child is an incarnation of an evil deity; at first, the husband thought it was a joke, but she seems completely serious. She has rapid mood changes, anxiety, and irritability. She has no history of any medical or psychiatric disease, though there is a family history of bipolar disorder. The husband asks if this could be a manifestation of thyroid disease.

Challenge: You hospitalize this woman for a medical emergency - what?

Image is in the public domain, from Wikipedia.

Grit

A 60 year old woman undergoes a multi-level lumbar discectomy for lumbar spinal stenosis. The surgery goes as expected and the patient is brought to the post-anesthesia care unit. In recovery, the patient starts complaining of severe left eye pain. "I can't open my eye," she says, "because it feels like grit or sand is in it." Her visual acuity is roughly baseline. A fluorescein stain is shown below.

Challenge: What's your diagnosis?

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Sunny Side Up

An 18 year old previously healthy woman has several months of an enlarging abdomen; one day, she presents with acute onset severe abdominal pain. She is found to have an ovarian mass which is removed. This is the histopathology:

The gross pathology is shown below. The tan, fleshy portion (green arrow) makes the diagnosis.

Challenge: What is it?

First image shown under GNU Free Documentation License; second image shown under Fair Use.

Look Closely

Challenge: What's the rhythm here?

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Sight

An 80 year old man who never sees a doctor is brought in by his children because of "weird" behavior. He has been running into doors, falling, knocking things off tables, and unable to locate anything. He says there's nothing wrong with his vision and that he's "just fine." When you show him three fingers, he says he sees two. When you do confrontation of his visual fields, it seems random which fingers he says are wiggling. When asked what color shirt his daughter is wearing, he says "red" when she is wearing a green shirt. He seems to genuinely believe what he is saying. A fundoscopic exam is shown above. An MRI makes the diagnosis.

Challenge: What's the diagnosis?

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Q&A

You get called by a public health department in Nova Scotia (or Switzerland, Great Britain, Germany, or southern France). They're wondering if you can help because a number of their sheep and goats have had spontaneous abortions, and some of their cattle have had low birthweight offspring.

"Um...," you say.

Well, they also want your opinion because a few of the farm workers and veternarians have come in sick. Most are men between 30-70 years of age. Some have presented with a self-limited flu-like illness with an abrupt high-grade fever, fatigue, headache, and myalgias. Others have presented with a mild nonproductive cough, fever, and a CXR shown below (A is normal, B is the patient).

Yet others present with hepatomegaly, fever, and increased LFTs. For most patients, the CBC is normal.

Here is the organism:

Challenge: What's your diagnosis?

Both images are in the public domain.

Beautiful Lady

A "beautiful lady" is brought to your emergency department by police for "bizarre behavior." She's red hot with cutaneous vasodilation yet not sweating. Her pupils are nice and dilated. She's anxious, babbling, agitated, dysarthric, and confused. "Everyone looks so small," she says. "It's like a Jonathan Swift book." (Okay, she might not have said that). She is only oriented to person and displays signs of paranoia. She reaches out and grabs invisible objects from the air. Exam shows absent bowel sounds. An EKG shows mild sinus tachycardia, otherwise normal. Finger stick glucose is normal. Labs and blood cultures are pending. A Foley is placed and 500mL of urine comes out.

Challenge: The police mention that she was found with the plant shown above. What's your diagnosis?

Image shown under GNU Free Documentation License.

Terms of Service

A 30 year old tennis instructor presents with right arm pain. After doing repetitive overhand serves, he gets forearm fatigue. This is accompanied by swelling, pain, and cyanosis. He notes paresthesias in the fingers occasionally. He also says he can see "blood draining from his arm through his shoulder, neck, and chest wall." A duplex ultrasound confirms your diagnosis. You start the patient on anticoagulation and refer to a surgeon.

Challenge: What's the diagnosis?

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