Thursday, July 30, 2015


A 60 year old man undergoes a coronary catheterization for unstable angina. He is found to have three vessel disease; there is no intervention and the plan is to refer him to cardiothoracic surgery. His other medical problems are hypertension, hyperlipidemia, and diabetes. However, after cardiac catheterization, the finding above was noted. His pulses are all normal. The toes are cool and painful but the rest of the foot is warm.

Challenge: What happened?

Image shown under Fair Use.

Monday, July 27, 2015


This gentleman is getting a sleep study. One of the waves noted on the EEG looked like this:

Challenge: What's the significance of this wave?

First image is in the public domain. Second image is shown under Creative Commons Attribution Share-Alike License.

Thursday, July 23, 2015


You are the technician trying to set up the system shown above. Here is the operating room schedule:
OR 1: Laparoscopic cholecystectomy
OR 2: Open partial nephrectomy
OR 3: Explantation of infected hip joint, irrigation with antibiotic solution
OR 4: Total knee replacement, use of methylmethacrylate
OR 5: CABG, Jehovah's witness

Challenge: Which room(s) might need the system shown above?

Image shown under Fair Use.

Monday, July 20, 2015

Dasher, Prancer, Vixen

Sorry about the disorganized cases; I've been traveling in Europe, and internet hasn't been as quick as easy as I hoped.

A basketball player comes in complaining of foot pain that occurred when he landed awkwardly after a jump. A runner has the same complaint when she inverts her ankle running on an uneven surface. Both are worried they sprained their ankle. Their pain is on the lateral edge of their foot. There is focal tenderness, bruising, and swelling at the base of the fifth toe. Both can walk but it's quite painful to do so.

Here is a radiograph:

Challenge: What's the diagnosis?

Image shown under Fair Use.

Monday, July 13, 2015

The Only Word Kids Dread More Than "Shots"

Visiting friends in Germany, I was asked to consult on the case of a two year old toddler who fell while trying to climb stairs too fast.

Child 1 has this image:

Child 2 has this image:

Challenge: Which, if any (or both) child needs to see a dentist?

Images shown under Fair Use.

Thursday, July 9, 2015

Access II

Similar case as the last one. An adult comes in as a major trauma alert. He was involved in a high speed car accident with a prolonged extrication. Unfortunately, all four extremities are mangled, and there is no place to put intravenous access. In addition, all sites for intraosseous access are contraindicated as well; he has tibial plate fractures, sternal fractures, and humeral head fractures.

In your emergency department, he goes into a ventricular fibrillation arrest, potentially from cardiac contusions sustained in the accident. As you start advanced cardiac life support, you wonder how you can give the epinephrine.

Challenge: Any ideas?

Image shown under Creative Commons Attribution Share-Alike License.

Monday, July 6, 2015

Access I

A child in a motor vehicle accident with prolonged extraction is confused, crying, agitated, and hypotensive. Multiple attempts at placing an intravenous line are unsuccessful. A nurse asks you if you can place an internal jugular central line. The child needs fluid resuscitation, antibiotics for open fractures, and analgesia.

Challenge: What's the most appropriate intervention here?