Looks Normal

A young woman with anxiety comes in because she says her heart beat is irregular. Her father has a history of atrial fibrillation and her mother has a history of a heart attack. Her EKG is shown above.

Challenge: How would you read this EKG?

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Terms of Agreement

A 20 year old G3P0 woman presents with left lower abdominal pain and vaginal discharge. She says she sometimes feels warm at night but hasn't had a marked fever. "I've had PID in the past, and this just isn't the same," she says. You are unable to do a complete pelvic exam because of significant adnexal tenderness. Because of this, you order pelvic imaging which is shown above. A CBC shows leukocytosis, and pregnancy test is negative. She undergoes surgery and cultures grow out a polymicrobial mix of E.coli, aerobic streptococci, Bacteroides, and Prevotella.

Challenge: What is the diagnosis?

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Strange Behaviors

A 60 year old man with depression is brought in by his wife for strange behaviors while he's asleep. His wife says that over the last few years, she's noticed repeated episodes of vocalization and movement while he's asleep. The movements last less than a minute long but are purposeful; she says she's seen him throw a ball. He often makes benign hand gestures, and occasionally punches or kicks. He sometimes shouts or yells. Most times, he doesn't awaken, but occasionally he wakes up momentarily before falling back asleep. He usually remembers his dreams, and when he awakes, he might be briefly confused, but orients quickly. All these episodes happen during the EEG shown above. For social history, he did not graduate high school, he currently smokes a pack a day, and he has some pesticide exposure from farming. Review of systems is remarkable for anosmia and constipation.

Challenge: In a decade, he is diagnosed with Parkinson's disease, but what does he have now?

Image is in the public domain.

Anosmia

A young man with difficulty smelling presents because his sense of smell has changed. He's "worried about a tumor." He also has nasal congestion, sinus fullness, and fatigue. He has no fever or pain. Exam of his nostrils shows the finding above in the middle meatus. This is resected and the gross pathology is below:

Challenge: What's shown?

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Reminder

A 65 year old man with hypertension, hyperlipidemia, history of stroke, congestive heart failure, and atrial fibrillation is brought in by EMS with shortness of breath and palpitations. Defibrillator pads are placed. His rhythm is shown above. His blood pressure is 100/50, and he is given amiodarone 150mg IV push. He converts to a normal sinus rhythm and blood pressures improve.

You then get called by the nurse because he became suddenly unresponsive. He has the same rhythm, shown above. His defibrillator pads are still on. The noninvasive blood pressure cuff cannot pick up a reading, and you cannot feel femoral or carotid pulses.

Challenge: What do you do?

Image is in the public domain.

Safer

A 35 year old woman with major depressive disorder is brought in with an overdose. She took a whole bottle of her antidepressants in an attempt to end her life. She currently complains of nausea and vomiting. She has some CNS depression and tremor but is protecting her airway. She has no muscle rigidity. Her vital signs are stable. EKG is normal sinus rhythm. Glucose is normal. Acetaminophen, salicylate, and ethanol levels are undetectable. Pregnancy test is negative. You give a single dose of 50g activated charcoal.

Challenge: What was the ingestion?

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Whoops!

Sorry! This week has come around and I have neglected to prepare cases of the day. Unfortunately, the free time I usually count on to write cases disappeared this last week. I apologize, but we'll both take this week off. Thanks for following!

Craig

Flintstones

A patient on a fad diet who does not eat oils, meat, eggs, and leafy vegetables presents with a spinocerebellar syndrome. She has ataxia, hyporeflexia, and loss of proprioceptive and vibratory sensation. She also has anemia with evidence of hemolysis. She starts taking vitamins and her symptoms improve.

Challenge: What's the most likely diagnosis?

Image is in the public domain.