Toxic

What toxic drug is responsible for the image above? It causes production of superoxide anions, hydroxyl radicals, and hydrogen peroxide. It leads to atelectasis, accentuation of hypercapnia, pulmonary parenchymal injury, and retinopathy. There is even some thought that it can be potentiated by bleomycin.

Challenge: What is it?

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Descartes' Soul

An 8 year old boy presents with slow onset, gradually progressive headaches and lethargy. This is accompanied by vision changes, nausea, vomiting, and most recently, impaired ambulation. His exam shows papilledema, ataxia, and loss of upward gaze. In fact, he has a downward gaze preference. Convergence and divergence are impaired, and bilateral ptosis is noted.

Imaging shows the following:

Challenge: What's your diagnosis?

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Risk Management

Challenge: Yikes! What are we looking at here?

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I Have this Disease

Ever since a child, this patient has had this disease. The skin is dry and itchy, and it involves mostly the hands, arms, and feet. The skin appears thickened with increased skin markings.

Challenge: What's your diagnosis?

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Curtains

This slit-lamp photograph is from a 60 year old gentleman with hypertension, hyperlipidemia, diabetes, myopia, and BPH. He presented acutely with a cobweb appearing in his vision followed by a large black housefly moving in and out of his central vision. He also had flashes of light.

Challenge: What's your diagnosis?

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The Loop

A 32 year old patient presents with a chief complaint of episodes of sudden onset palpitations and "weird feelings in the chest." This is accompanied by dizziness. When he has these episodes, his heart rate is 120-220. An EKG is shown below.

Breaking this arrhythmia can easily be done with adenosine, vagal maneuvers, calcium channel blockers, and beta blockers.

Challenge: What's your diagnosis?

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Palliation

You are a pain physician that performs a neurolytic block for a patient with metastatic pancreatic cancer and severe abdominal pain. He gets hypotensive which resolves with a fluid bolus. He also develops transient diarrhea lasting 48 hours. His pain improves, however, as he is transitioned to palliative care.

Challenge: What procedure did you perform?

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Emergency Options

A 30 year old woman with obesity, epilepsy, and HIV presents to your family planning clinic for emergency contraception. She had unprotected sex 24 hours ago and is worried about pregnancy. She normally does not use any type of contraception, and in fact, has presented for this same concern multiple times in the past year. Her HIV and seizures are well controlled on multiple medications. You counsel her about the risks of unprotected sex, especially in light of being HIV+.

Challenge: What type of emergency contraception is most appropriate here?

See the Stars

A 1 year old boy is brought in by his mother because he suddenly developed intermittent episodes of inconsolable crying. He draws his legs up towards his abdomen during these episodes which happen at 15-20 minute intervals. He initially had non-bilious emesis, but over the last hour, this has become bilious. Between episodes, the child behaves relatively normal.

He had an uneventful birth at full term. He has received all his vaccinations. You feel a sausage-shaped mass on the right side of abdomen.

Challenge: What's the diagnosis?

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