Arrow Sign

This is a high resolution CT scan of a healthy 25 year old volunteer.

Challenge: What do the arrows refer to?

Image shown under Fair Use.

Oops!

You are called to a stroke code. A 50 year old man who was admitted to the hospital with a complicated UTI developed the neuro finding above. He has a past medical history of hypertension, arthritis, and BPH. He has no known neurologic history. He was admitted to the hospital with dysuria and found to have a resistant strain of Pseudomonas. He was started on ciprofloxacin and gentamicin. He normally takes metoprolol, but ran out a couple months ago and was restarted on this hospitalization. This morning, his magnesium was slightly low and was replaced. The rest of his labs are fine. This neurologic finding resolves later this afternoon.

Challenge: What's your diagnosis?

Image shown under GNU Free Documentation License.

Stop Bang

A morbidly obese 35 year old gentleman who is 5'5" and 260lbs with a history of obstructive sleep apnea, hypertension, and insulin resistance undergoes pre-operative evaluation for a uvulopalatopharyngoplasty. He has excessive daytime sleepiness, loud snoring, witnessed apnea during sleep followed by a loud snort, fatigue, hypersomnolence, impaired concentration and memory, and a thick neck.

However, you also notice an elevated JVP, hepatomegaly, and some pedal edema. He has dyspnea on exertion and needs to rest after half a flight of stairs. An arterial blood gas shows a PaO2 on room air of 70, a PaCO2 of 48, a bicarbonate of 28, and a Hct of 55. Thyroid studies and electrolytes are normal. Pulmonary function tests show a low FVC, a low FEV1, a low ERV, but a normal FEV1/FVC ratio. EKG suggests right atrial and right ventricular hypertrophy. CXR is normal.

Challenge: Is there something else going on here?

Image is in the public domain, from Wikipedia.

Runaway

A man in his 30s is dropped off unconscious with multiple gunshot wounds. He is taken to the operating room where he has an exploratory laparotomy, total splenectomy, bowel resection, diaphragmatic repair, and bladder repair. Post-operatively, he leaves against medical advice and is lost to follow-up. He never gets any vaccinations.

Years later, he signs up for a research study for some money. A thoracic CT scan is performed which shows some lung nodules. He is a lifetime nonsmoker.

He decides to go to a physician and gets a heat-damaged RBC scintogram, shown below.

The rest of his review of systems is negative. Other than the gunshot wounds, he's never been sick a day in his life.

Challenge: What's going on?

Images shown under Fair Use.

Your Favorite Patient

A 35 year old woman with fibromyalgia and irritable bowel syndrome presents with 2 months of gradually worsening bladder pain, especially with a full bladder, relieved with voiding. The sensation varies from pressure and discomfort to painful spasms to severe debilitating pain. The pain is suprapubic and accompanied by urgency and frequency. There was no identifiable triggering event. This symptoms are worse with some foods, stress, and the menstrual cycle. There is no incontinence but she urinates up to 50 times a day to avoid pain. This has greatly affected her quality of life and ability to work. Examination shows tenderness of the abdominal wall, hip girdle, pelvic floor, bladder base, and urethra. The pelvic floor muscles are tight. Urinalysis is unremarkable and urine culture is negative. A post-void residual volume is normal. A cystoscopy shows reddened lesions on the bladder mucosa with attached fibrin deposits.

Challenge: What is your most likely diagnosis?

Limewater

I apologize for the missed case Monday - personal emergency. However, this is a good, rare case of the day which I had never heard of (or seen).

This chest X-ray is from a 30 year old man presenting with shortness of breath. He was treated with antibiotics without any improvement. Although sputum AFBs are negative, you take a social history to get an idea of his tuberculosis risk factors. He works in a Portuguese vineyard spraying plants with a fungicidal solution. The rest of his history is noncontributory; he is a nonsmoker. Pulmonary function tests suggest the lesion is interstitial. A thoracotomy was performed (this case is modeled after a case report from 1969) and the visceral pleura had areas that were blue.

Challenge: What's your diagnosis?

Image shown under Fair Use.