Balloon

Challenge: This CT is from a patient who suffered trauma to the torso but not to the head. What do you see?

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Rock and Roll

A 50 year old man presents for followup for osteoporosis. You're surprised that he's so young and has advanced bone disease. In fact, he's had fractures and vertebral compression in the past. You decide to send some labs. His labs are even more surprising. He has proteinuria, renal glucosuria, aminoaciduria, renal phosphate wasting, and hypercalciuria. This is his first diagnosis of kidney disease, but he doesn't have hypertension, diabetes, vascular etiologies, obstructive nephropathy, or polycystic kidney disease. He has smoked two packs per day for thirty years. He has worked for the last twenty years at a facility that makes nickle-cadmium batteries, alloys, and galvanizing pigments.

The next day, you see one of his coworkers in the emergency department. Apparently, there was an explosion at the facility; the coworker wasn't injured by anything, but developed cough and dyspnea. His initial chest X ray is clear. You admit him to the hospital, but over the next few days, he develops a severe pneumonitis with hypoxia and respiratory failure. His X-ray is consistent with ARDS.

Challenge: What is the cause of both these presentations?

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Counting

A 10 year old boy is brought in by his parents because of behavioral problems leading to poor grades at school. He says he has uncontrollable persistent thoughts about how his possessions at school are out of order or messy. He constantly counts and checks them and refuses to interact with anyone else while he does so. He also hoards candies, action figurines, and erasers. Attempts to convince him not to do these activities don't work; he says there are "rules he must follow." His parents both have anxiety. One sister has ADHD. A brother has autism.

Challenge: What's the most likely diagnosis?

Hold It Up

This ultrasound is from a G4P2 woman presenting with transverse lie. The infant is 32 weeks gestation with low birth weight. The patient had spontaneous rupture of membranes just half an hour ago. You are called emergently by the obstetrical nurse because of a sudden, severe, prolonged fetal bradycardia. On manual examination, you make the diagnosis.

Challenge: What are you most worried about?

Texas

It is the spring to summer months. You are in the southeastern, south central, and mid-Atlantic regions of the United States. White tail deer are abundant. A few people develop a disease with an incubation period 1-2 weeks presenting with fever, malaise, myalgias, headaches, and chills. A few have nausea, vomiting, arthralgias, and cough. A minority have rash or neurologic symptoms. Labs show leukopenia, thrombocytopenia, and elevated liver enzymes.

Challenge: It's easy to blame the bug above, but really, it's just a messenger. Don't shoot the messenger! Who's the culprit?

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A Boo

A 60 year old man with severe COPD on multiple inhalers and home oxygen presents with shortness of breath, productive cough, and increased work of breathing. In the emergency department, he has respiratory distress and is intubated. The resident sets a high minute ventilation in order to "blow off his CO2" since he is worried that the blood gas will be very acidemic. The patient then develops hypotension.

Challenge: Assuming this is not related to the patient's disease process, what is the cause of the hypotension?

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Barium

This barium swallow is in a patient with a history of trauma.

Challenge: What do you see?

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The Early Bird

Challenge: This is sometimes associated with osteogenesis imperfecta. What do you see here?

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