Pace Yourself

This EKG is from a patient with a dual chamber pacemaker that presents to the emergency room with presyncope. The resident says, "It's a paced rhythm, we can't interpret it."

Challenge: But you reply, "The patient's presyncope is from...what?"

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Diagram

This diagram is sometimes used by surgeons and anesthesiologists in cardiothoracic surgery and trauma.

Challenge: What is it?

Sounds Like a Magic Spell

Sorry for the late post - my call was busier than I expected.

That's one large boggy pustule on the scalp. It's tender and painful. It's seen mostly in children ages 5-10. Persistent disease can lead to alopecia.

Challenge: What is it?

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This Little Piggy Went to the Market

This patient complains of a burning pain in the space indicated radiating to the toes. The pain is worse when walking on hard surfaces or wearing tight shoes. Sometimes if she is active, the third and fourth toes become numb. Palpating the interspace and squeezing the metatarsal joints causes a clicking sensation. Ultrasound confirms the diagnosis. You begin conservative treatment with padded shoe inserts and physical therapy. You advise that further treatments can include injections of glucocorticoids and local anesthetics and surgery.

Challenge: What is it?

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Food

A 23 year old woman with a history of diabetes, hypertension, chronic pain, phobias, major depressive disorder, and alcohol dependence is brought in by her sister who is worried about an eating disorder. Her sister says the patient will eat unusually large amounts of food from time to time. The patient says she "just can't help it" and will eat rapidly until uncomfortably full, even when she is not hungry. The sister says the patient often eats alone because she feels ashamed and guilty. This has been happening once or twice a week for many months. Nevertheless, the patient denies purging, fasting, or excessive exercise.

Challenge: What is the most accurate diagnosis?

The Greatest

The top brain is a normal brain. The bottom brain shows the gross pathology of a professional athlete who developed cognitive impairment, behavior and personality changes, depression, speech and gait abnormalities, and Parkinsonism at the end of his life. Note the severe dilation of the second and third ventricles, marked atrophy of the medial temporal lobes, and shrinkage of the mammillary bodies.

Challenge: What kind of sports did he likely participate in?

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Dough

"so went Satan forth from the presence of the Lord and smote Job with sore boils from the sole of his foot unto his crown"

Ever since this patient was a child, he's had skin problems. In his first few weeks of life, he had a papulopustular crusted rash on his face, scalp, upper trunk, and buttocks. He was diagnosed with atopic dermatitis. He didn't have any wheezing, food allergies, or hayfever, though, and there's no family history of atopic dermatitis. He's also had lots of skin infections, including abscesses, furuncles, cellulitis, and lymphadenitis. Oddly enough, sometimes he has infections that lack classic signs of inflammation; they don't always manifest with erythema, warmth, or tenderness.

His other medical problems include recurrent sinus and middle ear infections. He's had pneumonia once requiring hospitalization. He's had weird teeth; he kept his primary teeth leading to two rows of teeth. This was later corrected by a dentist. He has scoliosis. He's had a few orthopedic surgeries for fractures from minor trauma.

Challenge: What's your diagnosis?

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The Nose Knows

Challenge: What is it?

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Postpartum

This contrast-enhanced CT is from a young G2P2 woman who just had a vaginal delivery. She had a previous C-section but elected for a vaginal birth after Cesarean (also called trial of labor after Cesarean). After a long labor, she delivered a healthy baby successfully, but subsequently had persistent bleeding and abdominal pain.

Challenge: What's the diagnosis?

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