Reminder

A 5 year old child was exposed to this disease 10 days ago. He presents initially with fever, cough, runny nose, malaise, and loss of appetite. The mom is worried about flu, though no one around him has gotten the flu. On exam, you note some conjunctivitis. You're not sure what it is, but you feel it's likely a URI and send the patient home.

The patient returns 3 days later with the rash shown above. It began on the face and spread cephalocaudally and centrifugally to involve the neck, upper trunk, lower trunk, and extremities. The rash on the face has become confluent. Luckily, the rash indicates that the child will get better within 48 hours.

Challenge: What's the diagnosis?

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Inside-Out

A G1P1 woman immediately postpartum presents with severe vaginal bleeding. Her labor was remarkably quick for being primiparous, and her pregnancy was only complicated by fetal macrosomia. She has a history of leiomyoma. Along with severe bleeding, she has lower abdominal pain. The first one to arrive is a medical student who does a pelvic exam and says she feels a smooth, round mass protruding from the cervix. Her abdomen is flat. The patient quickly develops hemorrhagic shock.

Challenge: What's the diagnosis?

Stat Radiology Call

You are cross-covering the general surgery patients at the hospital when you get a call from radiology about a stat CT abdomen pelvis with contrast. It is for an alcoholic presenting with abdominal pain radiating to the back, nausea, and vomiting.

Challenge: What's the radiologist going to tell you?

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Flesh Bladder

There are two distinct manifestations of this disease.

The first is seen in a man who eats undercooked beef or pork. After one or two days, he develops nausea, vomiting, abdominal pain, bloating, and watery diarrhea. Symptoms are self-limiting and resolve within 36 hours.

The second is a patient who traveled to rural Malaysia and encountered snakes. After about a week and a half to two weeks, he develops fevers to 39 C, rigors, myalgias, and headaches. This becomes a relapsing-remitting course with episodes lasting 4-5 days. You note myositis with muscle tenderness and muscle swelling, especially in the muscles of mastication, calf muscles, and superficial back muscles. Here's a T2-weighted short tau inversion recovery (STIR) MRI sequence:

In both cases, patients have eosinophilia and lymphocytosis. The other cell lines are fine. AST, ALT, and GGT are elevated moderately (less than twice the upper limit of normal) and CK is moderately elevated. A biopsy is shown below:

Challenge: What's the diagnosis?

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Diet II

A patient says her doctor recommended that she start a diet with four to five servings of fruit, four to five servings of vegetables, two to three servings of low fat dairy per day, and less than 25% of her dietary intake from fat.

Challenge: What medical condition is this diet supposed to treat?

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Diet I

After a 24-48 hour period of fasting, the patient (usually a child) ramps up his diet to goal, which takes on average four days. Glucose is monitored every six to eight hours and urine is monitored daily. The goal is four parts fat to one part protein and carbohydrate. Patients are given a carbohydrate-free multivitamin, calcium, and vitamin D.

Challenge: What's the diet and what is it for?

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Buddies

A 35 year old woman is brought in by her boyfriend because of abdominal pain. She's noted to have a fever by the emergency department triage nurse. On exam, you note some abdominal distension, lower extremity edema, jaundice, and confusion. Apparently, these changes have happened over the last few weeks. AST/ALT are in the 400 range, alkaline phosphatase 350, and bilirubin 4. The paracentesis shows high serum to ascites protein gradient.

Challenge: What's the diagnosis?

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Thyme, Lavender, Parsley, Basil

Challenge: What's the finding here?

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