Well?

ECG Wave Maven has been my go-to resource for great EKG's. Created by Beth Israel Deaconness Medical Center in 2001, it has an incredible number of fascinating cardiograms, cases, and explanations. It's an unsurpassed repository for learning and education, and I hope you check it out.

This EKG comes from a middle aged man with vague chest pain. Initial troponins are negative.

Challenge: What does the EKG show? (Click for full image)

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Exit Here

This CT scan is from a young woman with a pulsatile supraclavicular mass on the left side. She also gets pain with exertion in that arm. Sometimes, she gets pallor, paresthesias, and coldness in her left hand, and she was initially diagnosed with Raynaud's but wants a second opinion. There is no history of trauma. She has no other medical problems. Her pulses on that arm are diminished. There is no musculoskeletal tenderness.

Challenge: This is the least common version of what syndrome?

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Fall

Challenge: When does this go away?

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Delay

A 50 year old smoker comes in with severe headache, altered mentation, and this CT scan. He goes to interventional radiology for a procedure. Over the next several days, he slowly improves. A week later, though, he suddenly gets worse. He becomes more confused and somnolent. CT and EEG do not explain his neurologic exam. Ultrasound confirms the diagnosis.

Challenge: What do you suspect?

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Postpartum

A woman has postpartum hemorrhage from placenta previa after a spontaneous vaginal delivery. Despite adequate resuscitation, she has persistent hypotension and spends several nights in the ICU. Eventually, she is discharged home, though her blood pressures remain quite low. She has some symptoms of orthostasis but really wants to go home. On her first postpartum visit, she notes that she hasn't been lactating. A few weeks later, she also complains of fatigue and anorexia. A year later, she has persistent oligomenhorrhea.

Challenge: What syndrome do you suspect?

What'd I Miss?

Challenge: What kind of highly unstable fracture is shown above?

P.S. Taking a break on cases this weekend, back on Monday.

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Sphygmomanometer

I can't believe I've written 9 years of cases, almost a thousand of them, and didn't get to this one. This is the the kind of medical trivia I like.

You pump this blood pressure cuff on the arm of a patient to 200mmHg. The phone rings and you go and answer it. The BP cuff is left inflated for three minutes, and the patient begins having adduction of the thumb, flexion of the MCP joints, extension of the IP joints, and flexion of the wrist.

In addition, when you tap the patient just anterior of the ear, she gets contraction of the ipsilateral facial muscles.

Challenge: What's going on? What two signs are described above?

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Sign Here

Challenge: What does the arrow indicate?

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My Fair Lady

My goal for the last handful of cases on this blog is to actually post a case a day; it always bothered me a little to have a blog titled "Case of the Day" that was only running twice or thrice weekly posts. This may not actually happen, but I'm trying to go out with a bang.

These CT images are from an older Caucasian woman infected with a nontuberculous mycobacterium. She has a chronic cough but no known chronic lung disease. She tries to hide her cough.

Challenge: What syndrome is this?

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Africa

This disease is common in rural Africans, but can also be seen with travelers returning from Africa or the east Caribbean. It presents as a mild illness with headache, fever, and myalgias. Solitary or multiple eschars as shown above are common, along with regional lymphadenopathy. There may be a scant generalized rash, and uncommonly, subacute neuropathy or myocarditis.

Challenge: What is your diagnosis?

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Post-Op

An obese (BMI 40) man with diabetes, peripheral artery disease, and tobacco abuse undergoes a CABG. He actually had a prior cardiac surgery to repair an aortic valve five years ago. Over the last year, he developed increasing shortness of breath. Workup revealed coronary disease so he underwent a redo sternotomy and bypass graft with an internal mammary artery.

Postoperatively, he has fever, tachycardia, and persistent chest pain. There is crepitus and edema of the chest wall as well as a crunching sound synchronous with the heart beat and heard by auscultation. White count is elevated.

Challenge: That weird crunching sound has a name - what is it? Also, what's the diagnosis?

Vessel

This vessel starts at the junction of the left subclavian and left internal jugular veins, passes lateral to the aortic arch, and drains into the right atrium via the coronary sinus.

Challenge: What is this rare anomalous vessel?

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Whoops

A 70 year old patient comes in with septic shock. She is febrile, tachycardic, hypotensive, tachypneic, and hypoxemic. Her labs show a leukocytosis, elevated lactate, and elevated procalcitonin. Chest X-ray shows a right lower lung focal opacity. She is fluid resuscitated with 5 liters of crystalloid but still has refractory hypotension. The emergency medicine intern puts in a right internal jugular central venous catheter to start norepinephrine. Later, a KUB is taken which is shown above.

Challenge: What complication happened here?

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DDX

A rapid response alert is called in labor and delivery. You rush in to find a woman who has just delivered who appears in acute respiratory distress. The obstetrician says, "she had postpartum bleeding from uterine atony, but I don't think she's lost more than a liter of blood." You can't get a history because the patient can barely speak. On exam, her breath sounds are very tight; she's not moving much air, and you hear expiratory wheezes. Her blood pressure and heart rate are fine. She's maintaining a sat of 90% with oxygen by face mask. Fluids are wide open along with oxytocin.

Challenge: She received one other medication which is causing her clinical presentation. What is it?

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