Case of the Day

Manicure

2012-02-09T09:00:00.000-08:00

These images show the friable slow-growing nails in a 40 year old woman with pleural effusions, bronchiectasis, frequent pneumonias, and swollen lower extremities.

Challenge: What's your diagnosis?

First two images are in the public domain. Third image is shown under Creative Commons Attribution Share-Alike License.

Tut

2012-02-06T09:00:00.000-08:00

Some people believe that the person shown above suffered from a syndrome characterized by congenital fusion of cervical vertebrae, though others dispute the claim. Below is shown an image of a patient who actually has the disease.

A variable number of vertebrae can be fused, which may result in atlantoaxial instability. There are autosomal dominant, autosomal recessive, and sporadic variants. Significant scoliosis develops in more than half of affected children. The most common sign is limitation in range of motion of the neck. Some patients also have a low hairline and short neck. Associated findings include deafness, genitourinary abnormalities, and cardiovascular abnormalities.

Challenge: What's this disease?

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

Frog

2012-02-02T09:00:00.000-08:00

Challenge: This gentleman has a smoking history where the number of pack-years is three times his age. Yikes! What's the radiologic diagnosis?

Image shown under Fair Use.

Gutenberg

2012-01-30T09:00:00.000-08:00

This 1680 painting and these photographs both depict the same disease. These patients are often born by C-section due to breech, decreased fetal activity, and polyhydramnios. Prenatal ultrasound might show unusual positioning of hands and feet. As neonates, patients demonstrate profound hypotonia, feeding difficulties, a weak cry, and genital hypoplasia. Toddlers are slow to acquire their motor milestones, and starting between age 1-6, they become obese from eating a lot. Patients are often short and have growth hormone deficiency. Most patients show some behavioral problems and learning difficulties.

Challenge: What's your diagnosis?

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

Piddly

2012-01-26T09:00:00.000-08:00

A 22 year old woman comes into clinic complaining of lower abdominal pain, worse with jarring movements, which started just after her period finished. It's been going on for a week. The pain does not localize to any particular side. The patient also has some fevers, chills, and vaginal discharge. She denies nausea, vomiting, diarrhea, dysuria, or change in bowel habits. The patient has multiple sexual partners and uses an oral contraceptive. She has no past medical or surgical history.

On exam, the patient is afebrile. Abdominal exam shows tenderness in the lower quadrants with rebound. Bowel sounds are diminished. Pelvic exam shows endocervical discharge, adnexal tenderness, and cervical motion tenderness. The pain and tenderness do not lateralize to any side.

Ultrasound is shown below:

The ovary is marked OV and the arrows point to the Fallopian tube.

Challenge: What's your diagnosis?

Image shown under Fair Use.

In the News

2012-01-23T09:00:00.000-08:00

Challenge: This X-ray has been in the news lately. I thought it was pretty cool. What's going on here?

Image shown under Fair Use.

SOPA and PIPA

2012-01-19T09:00:00.000-08:00

No case of the day today. I instead encourage you to learn about two bills before Congress now, called Stop Online Piracy Act and Protect IP Act. These bills would make websites and blogs like Case of the Day impossible. I use images from many different websites, all for educational purposes, which could be illegal under interpretation of SOPA and PIPA. If you enjoy Case of the Day, then I encourage you to advocate against these bills.

We will return to our regularly scheduled case on Monday. Thanks!

-Craig Chen, MD

Near and Dear

2012-01-16T09:00:00.000-08:00

This is a rare neurodegenerative condition with a characteristic non-contrast CT scan shown above. Its phenotypic presentation is variable with features of parkinsonism, chorea, dystonia, cognitive impairment, and/or ataxia. Patients are between 20 and 60, and there is a familial form inherited as an autosomal dominant disease.

Challenge: What is it?

Image shown under Fair Use.

Sapling

2012-01-12T09:00:00.000-08:00

Challenge: These are examples of what kind of fracture seen in pediatrics?

First image shown under GNU Free Documentation License; second image shown under Fair Use.

Intern Fatigue Syndrome

2012-01-09T09:00:00.000-08:00

A 25 year old medical student is concerned because she has chronic daytime sleepiness. She keeps a sleep diary but sleeps exactly the same amount as classmates without chronic sleepiness. The patient is often so sleepy that she falls asleep suddenly at inappropriate times. Often when she takes notes in class, she just writes off the end of the page; she's also missed her highway exit several times. She feels most awake in the morning and right after naps.

Furthermore, just when she is falling asleep and occasionally when waking up, she has vivid frightening hallucinations. They are visual, tactile, and auditory. Immediately after awakening, she sometimes feels that she is paralyzed and cannot move for a minute or two.

Review of systems is positive for weakness only with laughing. Weird? Weird! This weakness happens mostly in the face, neck, and knees and is associated with strongly positive emotion. It lasts only a minute and does not interfere with consciousness. She does not snore and is not obese.

Challenge: What's your diagnosis?

Up High, Down Low, Too Slow

2012-01-05T09:00:00.000-08:00

You are the anesthesiologist on call and get paged by labor and delivery for an urgent C-section for failure to progress. You meet the patient for the first time in the operating room; she is 30 years old, G1P0 at 39 weeks, morbidly obese with gestational diabetes. Given her morbid obesity, you elect against general anesthesia and decide to place a spinal anesthetic instead. You position the patient, place local lidocaine, and go in with a standard spinal needle at L3-4 (you think; the morbid obesity makes it hard to feel landmarks) but are unable to get into the subarachnoid space. You try again one level higher at L2-3 and manage to get into the CSF. You inject 1.8mL of hyperbaric bupivicaine and 10mcg of fentanyl.

You lay the patient down and achieve surgical anesthesia quickly. The obstetricians begin working but because of the large pannus, they ask you to put the patient in steep Trendelenberg and have two nurses hold back the pannus as they work. Soon the patient becomes hypotensive. You run in fluids wide open and put a roll under the patient's right back to take pressure off the vena cava. The surgeons are getting into some blood loss, but not enough to explain the hypotension. She continues to remain hypotensive but is not particularly tachycardic. You ask her how she feels and she starts complaining of nausea and dyspnea. Her respiratory rate drops to 10, then 8, then 6. You end up intubating her emergently.

Challenge: What do you think happened?

Image shown under Creative Commons Attribution Share-Alike License, from Wikipedia.

Moon

2012-01-02T09:00:00.000-08:00

A 30 year old woman reports sudden intense right lower quadrant abdominal pain after going to the gym. This pain was also accompanied by some light vaginal discharge. She presented to urgent care where she had normal vital signs. Physical exam showed moderate tenderness to palpation on the right lower quadrant with minimal rebound and guarding. Pelvic exam showed mild cervical motion tenderness and slight adnexal fullness. Laboratory studies are normal and a pregnancy test is negative. Urinalysis shows pyuria. A CT abdomen/pelvis is shown below.

Challenge: Lots of things present this way; what is your diagnosis?

Images shown under Fair Use.

Do Sweat the Small Stuff

2011-12-29T09:00:00.000-08:00

A 50 year old patient with hypertension, diabetes, arthritis, and obesity gets the procedure shown above. Six months after the procedure, he is doing well; he no longer needs antihypertensives or insulin; he only takes some metformin and vicodin. The surgeons say he can go back to his regular family doctor so he shows up at your office. His only complaints are a new numbness and tingling at the tips of his fingers and toes. His laboratory studies show a microcytic anemia.

Challenge: What is the cause of these signs and symptoms?

Image is in the public domain.

Open Ended Question

2011-12-26T09:00:00.000-08:00

You are working in the clinical laboratory and get an arterial blood gas: pH 7.27, PCO2 70 mmHg, serum HCO3 31 meq/L.

Challenge: Your mentor asks you to interpret. Is the patient compensating for the acid-base disturbance?

Wild Wild West

2011-12-22T09:00:00.000-08:00

The EEG shown above was taken in a 6 month old child who is brought in because of recurrent motor spasms. You observe a video taken by the parents which shows symmetric movements starting as sudden brief contractions of muscle groups lasting a second followed by a longer tonic phase lasting 2-10 seconds. Some involve sudden flexion of the neck, trunk, arms, and legs; others involve extension of the neck and trunk with abduction of the legs. Occasionally the eyes show nystagmus. Changes in respiratory pattern occur commonly. The parents say the attacks occur in clusters up to a peak, then decline until they stop. When you consult the chart, you also note neurodevelopmental delay.

Challenge: What syndrome is described here?

Image shown under Fair Use.

Not A STEMI

2011-12-19T09:00:00.000-08:00

A 60 year old man with hypertension, arthritis, and multiple myeloma presents with constipation, anorexia, weakness, and nausea. As per usual ER protocol, he gets a CT abdomen which shows kidney stones as well as the multiple myeloma. He also gets an EKG, shown above.

Challenge: What's going on?

Image shown under Fair Use.

Hangman

2011-12-15T09:00:00.000-08:00

A 42 year old woman undergoes screening colonoscopy because she has a positive family history for cancer. The patient's mother died of endometrial cancer; her sister has colon cancer at age 39; her grandmother (on her mother's side) had ovarian cancer and colon cancer; her uncle (on her mother's side) had transitional cell cancer of the ureter. Her colonoscopy is shown above.

Challenge: What do you suspect?

Image is shown under GNU Free Documentation License.

Old Timer

2011-12-12T09:00:00.000-08:00

Challenge: Why does this patient have what looks like ping pong balls in his lungs? By the way, he got this treatment in the 1940s.

Image shown under Fair Use.

Odd Set of Risk Factors

2011-12-08T09:00:00.000-08:00

A 30 year old man comes in with fevers, chills, malaise, and myalgias. He has no significant past medical or surgical history. He takes no medications. He has no allergies. On review of systems, he notes dysuria, perineal pain, and cloudy urine. He also has urinary dribbling and hesitation. He initially thought this was a urinary tract infection and took a 2 week course of amoxicillin-clavulanate (Augmentin) but his symptoms persisted. He is an avid bike rider and has been training for 8-hours a day. He is not currently sexually active. He denies smoking, but drinks a beer occasionally and smokes marijuana occasionally.

If a biopsy were taken, the image above might be found.

Challenge: If this is more than a UTI, what is it?

Image shown under Creative Commons Attribution Share-Alike License.

Wrong Place, Wrong Time

2011-12-05T09:00:00.000-08:00

Both of these can be diagnosed with fetal ultrasound and materal serum AFP. Obstetrics, pediatrics, and surgery all play key roles in diagnosis and management.

Challenge: What congenital anomalies are seen here? (They are two distinct entities)

Both images shown under Fair Use.

Canada? Canada!

2011-12-01T09:00:00.000-08:00

A 40 year old man comes in with a soccer injury. He twisted his ankle in a game and has ankle pain. On exam, he can bear weight but limps. There is tenderness at the distal 6cm of the posterior edge of the fibula.

Challenge: Do you take ankle X-rays and why?

Image is in the public domain, from Wikipedia.

Demon

2011-11-28T09:00:00.000-08:00

A 30 year old man is brought in by police for a suicide attempt; he was found on a bridge, ready to jump. He says he wants to commit suicide because of symptoms exactly as those shown above: severe left orbital 10/10 pain occurring 6 times a day. All he can do is pace about or rock back and forth in his chair, waiting for the pain to stop. It's so excruciating that the affected eye waters and he gets congested. He's thought about committing suicide multiple times when these attacks start, especially after enduring them for a week, but each time he gets to the bridge, the pain stops for a few weeks.

Suddenly, the patient screams in pain and starts clutching the side of his head saying he is having an attack. On exam, you wonder if he has a unilateral Horner's syndrome. You're not sure because he does seem to sweat. His eye is pretty red and you wonder about conjunctivitis. The patient can't give further history but says it'll get better within the next 15-30 minutes. The rest of the exam is unremarkable, except for a pack of cigarettes in his shirt pocket.

Challenge: Other than danger to self, what's the diagnosis?

Image is shown under GNU Free Documentation License.

The Grecian Bend

2011-11-21T09:00:00.000-08:00

Hi everyone. I hope you have a happy Thanksgiving week. There will be no case on Thursday because of the holiday, but this is a great case - will post the answer next Monday.

This posture, seen with female socialites in the late 19th century, looks similar to workers building the Brooklyn Bridge in 1883.

These days, you don't see much of that disease. But instead, you see something related to the liquid shown above. You're on a plane flying from San Diego to New York when you hear an overhead page, "Are there any doctors on board?" Reluctantly, you hit your call button.

A few minutes later, you are rushed to the aisle-side of a 30 year old gentleman. "I knew I shouldn't have gotten onto the flight," he says. "In the airport, I just had the sense that something was wrong, I was tired, everything hurt, I had no appetite, and I had a splitting headache. Now, my elbows and shoulders hurt, and my chest itches. My arms and legs feel weak and they're tingly too."

When you examine the patient, he has full range of motion of his joints, pain is not exacerbated with movement, and there is no erythema or swelling of his elbows or shoulders. He does have some erythema on his chest and some mottling with cyanosis. His neurologic exam is significant for some mild weakness of the extremities. His pulse is 80. He doesn't feel febrile. You try to take the blood pressure with the airplane's sphygmomanometer and stethoscope but can't hear a thing. His respiratory rate is 18.

Challenge: You forgot to take a social history on this patient. What are his hobbies?

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

Stigma

2011-11-17T09:00:00.000-08:00

This patient notes that the lesion by his eye is numb. He also has hypopigmented lesions on his nose and testicles. All of these lesions have decreased sensation. On exam, you also note that he has no eyebrows. In fact, advanced forms of this disease can be associated with saddle nose deformities and hoarseness. On examination, some nerves appear enlarged and tender such as the greater auricular nerve, common peroneal nerve, and ulnar nerve.

Challenge: Thinking of the geographic distribution of the abnormalities, what's your diagnosis?

Image shown under Fair Use.

Overanxious Parents

2011-11-14T09:00:00.000-08:00

At a two-week visit, parents bring their newborn into your office, worried because she has had a few days of bloody mucoid vaginal discharge. A week later, this has resolved.

Challenge: What's the physiology?

Gender

2011-11-10T09:00:00.000-08:00

Two children present with the same disease.

A 5 year old boy is evaluated because he has gotten two urinary tract infections in the last six months. He is toilet trained and never has any problems. However, a renal ultrasound shows a dilated ureter.

A 5 year old girl presents with constantly wet underwear. She is toilet trained and has normal voiding habits but has persistent moisture in her underwear. When she sits in her parents' lap, this wetness is more pronounced.

Challenge: What's going on?

Image is from Wikipedia, shown under Creative Commons Attribution Share-Alike License.

Earthquake

2011-11-07T09:00:00.000-08:00

A 70 year-old patient is referred to neurology clinic, and before meeting the patient, you review the chart. This EKG stands out to you. Initially, you think it's one rhythm, but then you take a look at every single lead.

Challenge: What is the patient referred to you for?

Image shown under Fair Use.

Fentanyl

2011-11-03T09:00:00.000-07:00

A young man with no past medical history comes in after a motor vehicle accident. His primary and secondary trauma evaluations show a couple fractured bones and some ecchymoses. There are no other injuries. Both the resident and the attending each write for 100mcg fentanyl IV push for pain, and the nurse ends up giving 200mcg all at once. Suddenly, the patient has trouble breathing. He's awake and alert, so it doesn't appear to be respiratory depression from opiates; instead it seems that his tidal volumes have significantly decreased.

Challenge: How does the patient's chest wall feel and why?

Image shown under Fair Use, from usfca.edu.

Lemon

2011-10-31T09:00:00.000-07:00

Happy Halloween!

A young man presents with early systemic manifestations of a curious disease occurring one to two months after its initial onset. He comes to the medical system because of palpitations. You take an EKG and note something very peculiar. He goes from first degree AV block to second degree AV block to complete heart block to first degree AV block over the course of minutes. The patient works at a national park.

Challenge: A lot of clues in this case point to what disease?

Image is in the public domain.

Diagnostic Arrow Sign

2011-10-27T09:00:00.000-07:00

A 60 year old man with Crohn's disease undergoes a colonic and low anterior resection that is uncomplicated. He shows up to his follow-up appointment 6 days later and complains of low grade fever, prolonged ileus, moderate pain, and feculent drainage. Exam shows a mild tachycardia. Imaging is shown above.

Challenge: What's your diagnosis?

Image shown under Fair Use.

Ancient History

2011-10-24T09:00:00.000-07:00

This image is from a ward in 1918, filled with patients with the same disease. This disease typically presents with abrupt onset of fever, headache, muscle ache, malaise, cough, sore throat, and rhinorrhea. Exam shows hyperemic mucosa and mild cervical lymphadenopathy, but little else. Complications include persistent high fever, dyspnea, bilateral reticular or reticulonodular opacities, secondary infection, rhabdomyolysis, encephalitis, transverse myelitis, aseptic meningitis, and Guillain-Barre syndrome.

Challenge: What is the molecular mechanism by which such pandemics occur?

Image is in the public domain.

Hurricane II

2011-10-20T09:00:00.000-07:00

This is the second part of a two-part case; please see the prior post.

You confirm your diagnosis and begin treatment which is shown above (given as an IV bolus of 1-2mg/kg over 5 minutes). The patient does not get better after a few hours. In fact, he seems to get worse; he's more dyspneic. You decide to send another panel of labs, and when they come back, you note that the hemoglobin has dropped 3 points and the blood smear shows:

Challenge: What happened?

Image shown under Creative Commons Attribution Share-Alike License.

Hurricane I

2011-10-17T09:00:00.000-07:00

This is the first part of a two-part case.

You are on call covering a whole hospital of medicine patients when you get a call from a nurse that a patient who recently had an upper endoscopy has a sore throat. The patient is a 50 year old African American gentleman with hypertension and alcohol abuse who presented with coffee ground emesis. His EGD was negative. The plan on the sign out is to discharge him the following day. His labs look fine. You decide to write him for benzocaine 20% topical throat spray and his symptoms resolve.

Once the floor quiets down, you go to sleep, and at midnight, the nurse pages you and says the patient now has a headache, fatigue, and lethargy. You figure he's just not sleeping so you give him acetaminophen and zolpidem. You go back to bed.

At 3am, a code blue is called and you rush down to find...this patient. The code blue was called for respiratory depression and hypoxia. You note an oxygen saturation of 86% and the patient is minimally arousable. You go ahead and get an arterial blood gas, shown in the image. The patient's ABG is the tube on the left; a control ABG is on the right.

Challenge: The results of the ABG are pending, but your initial diagnosis is...what?

Image shown under Fair Use.

Worth Your Salt

2011-10-13T09:00:00.000-07:00

Challenge: Worldwide, what is the most common cause of this condition?

Image shown under GNU Free Documentation License.

Ambiguous

2011-10-10T09:00:00.000-07:00

You deliver an infant who has ambiguous genitalia. The child is born at 38 weeks to a 32 year old G1P1 Caucasian woman. The parent declined all prenatal screening and testing. At birth, a karyotype is 46,XX. You note clitoral enlargement, labial fusion, and formation of a urogenital sinus. She is at risk for early puberty and short stature.

Challenge: What is this autosomal recessive disorder?

Split Spine

2011-10-06T21:26:00.000-07:00

I apologize - this case was meant to be posted in the morning.

This child, shown on her back, was born to a mother who had prenatal AFP screening that was positive. The child has bowel and bladder incontinence and does not seem to move his feet.

Challenge: What's your diagnosis?

Image shown under Fair Use.

Cherry

2011-10-03T09:00:00.000-07:00

A middle-aged patient presents with these on the trunk. They bleed profusely if cut. They blanch with pressure.

Challenge: What's your diagnosis?

Image shown under Fair Use.

One After Another

2011-09-29T09:00:00.000-07:00

The patient shown above, in his 20s, underwent surgery to remove both his adrenal glands.The symptoms shown above improve but then he develops the finding below a couple years after surgery.

Challenge: What is this syndrome? Why does it happen?

First image shown under Fair Use, second image shown under GNU Free Documentation License.

Two Sides of the Same Coin

2011-09-26T09:00:00.000-07:00

Back to real hardcore diagnosis:

Case 1: A soldier returning from Afghanistan presents with the skin lesion shown below.

It began as a red papule and evolved to the lesion shown above. There is no surrounding induration. The lesion is completely (and surprisingly) painless. There is some local adenopathy. Without treatment, this lesion will resolve spontaneously, leaving only a residual hypopigmented depressed scar.

Case 2: A photographer who travels worldwide presents with subacute insidious fatigue, malaise, fever, and weight loss over months. The spleen is markedly enlarged but minimally tender. Labs show a severe anemia. The patient notes his skin has "darkened" over the last few months. Without treatment, this disease is lethal. Bone marrow aspirate is shown below.

Challenge: Maybe these serve as hints: What is the Hindi name for the second disease? What insect acts as a vector? What's the diagnosis in each case?

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

Doesn't Bind GABA Receptor

2011-09-22T09:00:00.000-07:00

A 25 year old woman with bipolar disease attempts suicide by overdosing on gabapentin. She's taken about one hundred 400mg tablets.

Challenge: What's your antidote?

Scheduling Glitch

2011-09-18T11:54:00.000-07:00

Many apologies - the last case did not get posted as scheduled (the Blogger interface was updated recently so I've been adapting). It is now up, but I'll post the following case this Thursday, and then we'll be back on schedule.

Craig

You're in Court... II

2011-09-15T09:00:00.000-07:00

A 50 year old gentleman with CAD, HTN, hyperlipidemia, DM, diverticulosis, hypothyroidism, and opiate dependence in remission is scheduled for a 3 vessel coronary artery bypass graft tomorrow. His medications include metoprolol, lisinopril, atorvastatin, levothyroxine, naltrexone, and aspirin. He has a two flight of stairs exercise tolerance. His exam and labs are unremarkable. The patient stopped his aspirin 7 days ago. You tell him to hold his lisinopril and naltrexone tonight. He takes his metoprolol on the day of surgery.

Challenge: You're in court... Why?

Image is in the public domain, from Wikipedia.

You're in Court... I

2011-09-12T09:00:00.000-07:00

This week's cases are about pre-operative evaluations gone wrong.

A 70 year old gentleman presents to the pre-operative clinic because he is scheduled for a repair of a 6cm abdominal aortic aneurysm. His other medical problems include HTN, DM, COPD, arthritis, GERD, and obesity. He is an active smoker, though trying to cut down. His medications include losartan, metformin, tiotropium, albuterol, fluticasone, omeprazole, ibuprofen, and aspirin. Due to his arthritis and COPD, his exercise tolerance is one flight of stairs slowly. However, when he climbs a flight of stairs, he gets mild substernal chest pain which stops when he rests. It has been going on for several months but has not changed in character, severity, or frequency. EKG is NSR with LVH. Troponin is negative. Because of his reactive airway disease, adenosine stress test is contraindicated. You order a dobutamine stress test prior to his vascular surgery and refer him to cardiology.

Challenge: You're in court...Why?

Image is shown under Creative Commons Attribution Share-Alike License, from Wikipedia.

Don't Treat a Number

2011-09-08T09:00:00.000-07:00

A patient (usually seen in children, but described in adults) presents with fever, hepatomegaly, splenomegaly, nonspecific rash, lymphadenopathy, and neurologic symptoms. Labs show cytopenia in two cell lines, high triglycerides, low fibrinogen, elevated liver enzymes, and decreased coagulation factors.

Challenge: Everything above is pretty nonspecific, but what if the patient had a ferritin level of 20,000 micrograms/liter? What would your leading diagnosis be?

Image shown under Fair Use.

Labor Day Weekend

2011-09-05T09:00:00.000-07:00

An umbilical artery arterial blood gas is obtained in a 34 week newborn right after a prolonged delivery to a G1P1 30 year old mother. The ABG reads: pH 7.25, pCO2 50 mmHg, HCO3- 23 mEq/L, and base excess -3 mEq/L.

Challenge: What's your interpretation?

Image shown under GNU Free Documentation License, from Wikipedia.

Know Thyself

2011-09-01T09:00:00.000-07:00

A patient with leukemia undergoes an allogeneic hematopoietic stem cell transplant and is discharged on cyclosporine and tacrolimus. He presents to his followup appointment one week later with the arm shown above. He initially thought he had a sunburn on his neck, ears, shoulders, palms, and soles, but then it progressively got worse. It changed from an erythematous maculopapular rash to a confluent swelling with bullae. Review of systems is positive for severe diarrhea and abdominal cramping. The bowel movements started as watery but progressed to bloody. Liver enzymes show an elevated bilirubin and alkaline phosphatase.

Challenge: What's your diagnosis?

Image shown under Fair Use.

Alphabet Soup

2011-08-29T09:00:00.000-07:00

This is one of the more difficult EKGs I've found. This is seen in a young patient with no past medical history presenting with vertigo. Her electrolytes were normal. Cardiac enzymes were normal. Cardiac cath was normal.

Challenge: What do you see? Where's the lesion?

Image shown under Fair Use.

Pouch of Wrath

2011-08-25T09:00:00.000-07:00

A 10 year old child is brought in by parents because her teacher has noted that she has visual impairments. You note decreased peripheral vision on exam. On her growth chart, you note that she is 3% of her expected height and weight. She has no signs of puberty yet. The only complaint she has is headache. Laboratory testing shows decreased growth hormone, GnRH, and TSH.

Challenge: What's your diagnosis?

Image shown under Creative Commons Attribution 2.0 License.

From First Year of Medical School

2011-08-22T09:00:00.000-07:00

Challenge: What is this test, and what is it for?

Image shown under Fair Use.

An Eye for Details

2011-08-18T09:00:00.000-07:00

Yikes! This is an older patient who has diabetes, hypertension, atrial fibrillation, chronic constipation, and a recent URI who had no eye symptoms and was quite unaware of this finding until he looked in a mirror. His visual acuity is unchanged. There is no photophobia, discharge, or foreign body sensation.

Challenge: What's your diagnosis?

Image shown under Creative Commons Attribution Share-Alike License.

From Latin for Glue

2011-08-15T09:00:00.000-07:00

Challenge: What has this patient been eating?

First image is in the public domain, second image shown under Creative Commons Attribution Share-Alike License, third image shown under GNU Free Documentation License.

NSFW

2011-08-11T09:00:00.000-07:00

This man presented with severe pain of his butt with spread of the disease to the anterior abdominal wall, penis, and scrotum. The patient also has diabetes and peripheral vascular disease. Blood cultures grow out both aerobic and anaerobic organisms. You page urology stat.

Challenge: What's this eponymous diagnosis?

Image shown under Fair Use.

Number the Stars

2011-08-08T09:00:00.000-07:00

This 19 month old girl was brought in for 4 days of fever to 104 degrees (40C). She was slightly irritable, but otherwise active, well-appearing, and alert. The mother was concerned about the fever, but this morning the fever broke abruptly. However, you do notice this rash, starting on the neck and trunk and spreading to the face and extremities. It is blanching, flat, and not itchy.

Challenge: What's the cause of these symptoms?

Image is in the public domain.

Sweetbread

2011-08-04T09:00:00.000-07:00

A patient comes to your office complaining of longstanding depressed mood for at least several years. He feels "depressed" on "many days," and this is accompanied by poor appetite, poor sleep habits, low energy, poor self esteem, and poor concentration. However, he does not feel this way for "most of the day nearly every day for two consecutive weeks." Instead, it appears to be more of a chronic feeling rather than an episodic one. He does not have psychomotor agitation or retardation, thoughts of guilt or worthlessness, thoughts of suicide, or symptoms of mania.

Challenge: What do we call this?

Two Passengers

2011-08-01T09:00:00.000-07:00

A 30 year old G2P1 woman at 28 weeks gestation is taken to the emergency department after a car accident. She was T-boned by a car which hit the passenger's side, but likely she was on the driver's side. On arrival, she says she "can't catch her breath."

The patient is afebrile. Heart rate is 100, blood pressure 100/60, respiratory rate 14, O2 sat 100% on room air. Extremity exam shows mild peripheral edema and a small water hammer pulse (rapid rise and brisk collapse). The JVP is easily visible. The apical impulse of the heart is at the fourth intercostal space, midclavicular line; it feels relatively hyperdynamic, though not sustained. Heart sounds are easily audible including a widely split S1, an S3, and a 2/4 systolic ejection murmur over the pulmonary and tricuspid areas. There is also a venous hum.

EKG shows a left axis deviation, left atrial enlargement, and an inverted T wave in lead III. The CXR shows mild cardiomegaly with increased pulmonary vascular markings. Hemoglobin is 11, hematocrit is 31, WBC 14,000, platelets 250. ABG shows a PaCO2 of 32, PaO2 of 107, and calculated HCO3 of 20. Creatinine is 0.4.

Challenge: The attending says, "I checked out the fetus and the fetus is fine, but tell me about the mother."

Image shown under Fair Use, from chronicle.pitt.edu.

Typo

2011-07-28T09:00:00.000-07:00

You are cross-covering 80 floor patients overnight and a nurse calls you for one of them because her monitor keeps having the finding shown above. You look at the sign-out given and it's a 40 year old woman admitted for abdominal pain. The last set of labs were:
WBC 11, Hgb 11, Hct 31, Plts 210
Na 134, K 4.1, Cl 101, HCO3 22, BUN 12, Cr 0.9, Glucose 220, Ca 10, Mg 1.7, Phos 4
b-HCG negative
UA with 1+ leukocyte esterase and 5-10 WBC.

You stop by her floor and jot a quick order in the chart on your way to the call room. An hour later, you hear a rapid response being called for this patient. When you run to the bedside, you hear the nurse saying, "She isn't responsive. Her vitals are HR 62, BP 102/68, RR 6, O2 sat 94% on room air."

Challenge: This illustrates a JCAHO (Joint Commission on Accreditation of Healthcare Organizations) violation...what happened?

Image shown under Creative Commons Attribution Share-Alike License.

No Case Today

2011-07-25T09:00:00.000-07:00

Hi Everyone,

I rarely take a break, but I got behind so there's no case today. I'll find a good one for Thursday, so check back then. If you have any good ideas, feel free to post them in reply - I will see them and comments aren't automatically public, so it's a good way of sharing that factoid you just learned or case you just saw.

Craig

Anti-Fruitarian

2011-07-21T09:00:00.000-07:00

You are in General Surgery Clinic and you see a woman who has allergies to kiwi, banana, peach, avocado, chestnut, fig, bell pepper, tomato, and white potatoes. You roll your eyes. You ask what happens, and she says her throat swells up, she feels lightheaded, and she breaks out into generalized hives. She pulls two Epi-Pens from her pocket. She is scheduled for a laparoscopic hernia repair.

You present this case to your attending who, prior to being a surgeon, completed a medicine residency and an allergy and immunology fellowship. "Ah," she says, "11% of these patients will be sensitive to something in the operating room. And conversely, 35% of people who have that sensitivity show one of those food allergies." She draws the diagram shown above.

Challenge: When you call the operating room to schedule this case, you make sure they know she could have a reaction to...what?

P.S. Despite being Californian, your attending does not use organic locally harvested sustainable eco-friendly kiwi-skin meshes for her hernia repairs.

Image shown under Fair Use.

Chole

2011-07-18T09:00:00.000-07:00

A patient underwent the procedure shown above four days ago but returns with fever and abdominal pain. Labs show a leukocytosis and elevated bilirubin, alkaline phosphatase, and gamma-glutamyl transferase. A trans-abdominal ultrasound shows a contained collection of fluid in the gallbladder fossa.

Challenge: What went wrong?

Image shown under GNU Free Documentation License, from Wikipedia.

Free Living

2011-07-14T09:00:00.000-07:00

A young adult is rushed into the emergency department with acute onset headache, fever, neck stiffness, nausea, and vomiting. She notes that things taste and smell funny as well. Labs show a leukocytosis with elevated PMNs. A lumbar puncture has elevated opening pressure, PMN pleocytosis, increased protein, decreased glucose. She's started on appropriate antibiotics for bacterial meningitis, but she suffers progressive deterioration with seizures, ataxia, cranial nerve palsies, and confusion. Imaging shows cerebral edema, leptomeningeal enhancement, and areas of hemorrhage and necrosis. Finally, she falls into a coma and then dies. Lifecycle stages of the organisms recovered are shown above.

Challenge: How is this disease acquired?

Image is in the public domain.

Inconsistent

2011-07-11T09:00:00.000-07:00

A 60 year old man with hypertension, untreated colon cancer, and a history of NSTEMI presents to the emergency department with immediate onset dyspnea two hours ago. He is short of breath at rest. He has a cough with streaky bloody sputum and associated chest pain while coughing or taking a deep breath. He has two pillow orthopnea. He says he has been taking all his prescribed medications but forgot to bring in a list. His social history is significant for being mostly bedbound due to obesity and living alone.

On exam, vital signs are heart rate 70, blood pressure 110/70, respiratory rate 26, and oxygen saturation 90%. You hear a regular rate and rhythm. He has rales and decreased breath sounds. He has some jugular venous distension. His ABG is 7.50/30/68. His CXR is unremarkable. His EKG is normal sinus rhythm with several old Q waves.

Challenge: When you present your most likely diagnosis to your attending, he says that the heart rate isn't consistent. How do you explain the patient's heart rate?

Thrower

2011-07-07T09:00:00.000-07:00

This five year old child appeared normal at birth, but started having problems in the third month of life. At that time, she had developmental delay and recurrent respiratory infections with chronic nasal discharge. Although her growth was fine for the first year, this slowed by the second and third year to minimal. Her developmental milestones peaked at multiword sentences and walking at age 3, but has started to regress. Parents are concerned that her trouble walking is because of joint stiffness and contractures. Past medical history is significant for frequent ear, sinus, and pulmonary infections with thick secretions.

On exam, you palpate both the liver and the spleen as well as an inguinal hernia. The eye exam is noted below, and indeed, her vision and hearing has declined. While she is in the waiting room, she falls asleep and you note some sleep apnea.

Challenge: Unfortunately, the average life expectancy is 5 years and nearly all patients die before 10 years if they have what disease?

Images shown under Fair Use.

Blue Man Group

2011-07-04T09:00:00.000-07:00

Challenge: What's this patient's past medical history?

(Ooh! Isn't this a good case?)

Image shown under Fair Use.

Transgender

2011-06-30T09:00:00.000-07:00

A 40 year old transgender male to female patient establishes care with you for the first time. She says she was healthy until five years ago when she was diagnosed with hepatitis C cirrhosis. She established care at that time and is compliant with a diuretic regimen. However, she's had refractory ascites and edema. Indeed, when you examine her today, you note a tense abdomen with dullness to percussion at the flanks and a positive fluid wave. When you review labs she brought from her previous care provider, you note that she has an elevated CA-125 of 300 U/mL (normal 0-35 U/mL). There is no indication of why this test was sent.

Challenge: What's your interpretation of this test result?

Image of transgender pride flag is in the public domain, from Wikipedia.

Bronze

2011-06-27T09:00:00.000-07:00

This disease manifests at age 40 in men and later in women. Patients present with weakness, lethargy, arthralgia, impotence, diabetes, and dilated cardiomyopathy.

Challenge: What's your diagnosis?

Images shown under Fair Use.

Struck Dumb

2011-06-23T09:00:00.000-07:00

A previously healthy gentleman presents with sudden onset excruciating headache and diplopia. In the emergency department, he has persistent hypotension refractory to aggressive fluid resuscitation. A T1-weighted MRI is shown above.

Challenge: What's your diagnosis?

Image shown under Fair Use.

Home Call

2011-06-20T09:00:00.000-07:00

You are taking "home call" as a surgery resident. You're not really sure what this means until you get called by a patient who says she has "tingling in the lips and fingertips." You glance at your signout which says "s/p total thyroidectomy for thyroid cancer."

Challenge: What's your midnight diagnosis?

Image shows a rendering by Max Bro of a thyroidectomy performed by surgeon William Halsted, from www.jhu.edu, shown under Fair Use.

Not the Neck

2011-06-16T09:00:00.000-07:00

A 30 year old G6P3 woman in her second trimester is referred to your obstetrics practice because she has a history of mid-trimester losses as well as a history of short labors. She has three living children, and during those pregnancies, she has had successively earlier deliveries. On examination, you note cervical dilation to 4cm and 80% effacement even though she is only at 22 weeks. She has no painful contractions, vaginal bleeding, ruptured membranes, or signs of infection. There's been a slight change in the color of vaginal discharge from clear to light yellow which also seems thinner, but other than that, she's asymptomatic. Her other gynecologic history is only notable for an abnormal pap smear at age 25 for which she received LEEP.

Challenge: What is your most likely diagnosis at this point?

Odds

2011-06-13T09:00:00.000-07:00

You see a 40 year old woman in clinic who complains of pain at the bottom of her left foot. She says "I've been trying distance running and ballet to cut down on my weight." Her BMI is 30. On exam you do the following:

This elicits point tenderness. You get a screening complete blood count, basic metabolic panel, erythrocyte sedimentation rate, and C-reactive protein which are all within the normal range. X-rays are shown below (and labeled!):

Challenge: This could be many things, but what is the most likely cause?

Image is shown under Fair Use.

Hyphen

2011-06-09T09:00:00.000-07:00

You meet this patient with a rare autosomal recessive disease. She has a history of recurrent severe bacterial infections including pyoderma, skin abscesses, and ulcerations. They are often caused by Staphylococcus, Group A Streptococcus, and Pneumococcus. Her dentist follows her for gingivitis, oral ulcerations, and periodontal disease. She has had a few episodes of respiratory tract infections as well. On review of systems, the patient reports bruising easily and abnormal musocal bleeding.

On exam, you note hepatosplenomegaly and lymphadenopathy. Unfortunately, as she gets older, her exam may show weakness, sensory deficits, peripheral neuropathy, ataxia, tremors, cranial nerve palsies, and seizures. Laboratory tests show neutropenia. Blood smear is shown below.

Challenge: What is this hyphenated diagnosis?

Both images shown under Fair Use.

Araneae

2011-06-06T09:00:00.000-07:00

Yikes!

A boy comes in with a bite while putting on a shirt, and the spider above is the culprit. He didn't think much of it at the time since it wasn't initially painful. But over the next few hours, he started having more and more pain. He also has malaise, nausea, fever, and myalgias.

Initially, the parents describe erythema with two cutaneous puncture wounds on the skin. Over time, it developed a central pallor, and now on exam 2 days later, you note a dark, depressed eschar. It looks almost necrotic, and the area has decreased sensation.

Challenge: Identify the spider.

Image shown under Creative Commons Attribute Share-Alike License, from Wikipedia.

Hear Hear

2011-06-02T09:00:00.000-07:00

A patient comes to you complaining of hearing loss. He says that ever since he "caught a cold which worsened his allergies," he feels like his hearing is muffled, almost like he's under water. He can "pop" his ears and then they sound normal for a while. On exam, you see that the tympanic membrane is retracted without moving properly.

Challenge: What's your treatment of choice?

Image shown under GNU Free Documentation License.

Insult on Injury

2011-05-30T09:00:00.000-07:00

These biopsies are from a 60 year old gentleman who was admitted to the ICU for a severe COPD exacerbation. He has a known history of COPD, diabetes, and hyperthyroidism, was not taking his medications, and came into the emergency department with hypercarbic respiratory failure one week ago. He was intubated for airway protection due to altered mental status. He has been on high dose IV glucocorticoids for the COPD exacerbation.

He had a prolonged extubation due to difficulty weaning him from the ventilator. Even after he was successfully extubated, he complained of weakness and exam showed a flaccid weakness greater in the proximal than distal extremities affecting all limbs. His facial muscles are also weak, though extraocular movements are intact. Sensation is normal. Deep tendon reflexes are normal. CK is elevated.

Challenge: What is your main concern?

Image shown under Fair Use.

Pre-Op II

2011-05-26T09:00:00.000-07:00

You are evaluating a 50 year old smoker for lung resection for localized non-small cell lung cancer. Pre-operative pulmonary function tests include: FEV1 1.8 L, 75% of predicted, preoperative DLCO 90%, predicted post-operative FEV1 is 900mL or 45% of predicted.

Challenge: What is your interpretation of this data?

Image of pneumonectomy shown under Creative Commons Attribution Share-Alike License, from Wikipedia.

Pre-Op I

2011-05-23T09:00:00.000-07:00

This week's cases will be things seen in pre-operative clinic.
A healthy 55 year old gentleman is scheduled for a laparoscopic cholecystectomy for symptomatic cholelithiasis. He has not seen a doctor in ages but is "otherwise healthy." He has never had surgery before. He takes five herbal medications for "general wellness." He has no allergies. He smokes marijuana daily, but does no other alcohol or drugs. His vital signs are all within normal limits. His Mallampati score is II, he has good neck range of motion, and his heart and lungs are normal on exam. Because of his age, a screening EKG is obtained and shown above. The EKG computer says "abnormal EKG."

Challenge: Do you do the case or cancel it for further workup?

Image shown under Fair Use.

The Illusionist

2011-05-19T09:00:00.000-07:00

These images are from a patient with a "vanishingly" rare disease which affects children and young adults (age<40). Although almost any bone can be affected, the shoulder girdle, pelvis, and mandible are most common. The lesion is nonulcerative but locally aggressive. You take a biopsy which shows no malignant cells but intraosseous proliferation of hemangiomatous or lymphangiomatous tissue. Osteolysis is present. The disease is not hereditary. Some patients present with pain, swelling, or a pathologic fracture, while others are asymptomatic. There are no specific laboratory findings.

Challenge: Only 150 cases of this disease have been described; what is it?

Image shown under Creative Commons Attribution 2.0 Generic License.

Which Is It?

2011-05-16T09:00:00.001-07:00

Jaundice A starts at 3-5 days of life, peaking at 2 weeks. Total bilirubin levels are commonly >5 and mostly unconjugated. This is a relatively benign condition. Jaundice B starts at the first week of life in conjunction with weight loss and dehydration; it is seen more commonly in preterm rather than term infants.

Challenge: What is Jaundice A called? What is Jaundice B called?

Image shown under Fair Use, from newborns.stanford.edu.

Short Blogger Outtage

2011-05-13T20:36:00.001-07:00

Hi everyone,

There was a short outtage with the blogging service and so things are a little disrupted, but I should have a new case on Monday. The other thing is that this blog has been an immense privilege to put together and maintain. It began as a fleeting idea in the first year of medical school and has evolved to capturing some of the complexity, mystery, and fascination in medical diagnosis. I've found this entire experience to be incomparably educational for myself. However, I think that I am slowly edging toward closing this blog. It was never meant to be an endless project, and over the course of the last four years, I've explored over 500 medical diagnoses (and to think about it, I'm pretty happy to have read the same number of UpToDate articles for this blog). As I begin advanced training in anesthesiology, I will turn my attention and time to other things. I still have a host of cases to explore so I'll probably keep chugging away for the next couple months but I wanted to give you a heads up. Thank you for your time and your interest, and good luck on all your endeavors.

Craig Chen, MD

Mike and Ike

2011-05-09T09:00:00.000-07:00

You are doing home visits and stumble upon this scene. The patient admits to doing IM shots of street drugs. "But it's cool, I clean the needle before I inject." You ask him how he cleans the needle and he says, "I lick it." Unfortunately, he has an erythematous tender area over his deltoid where he injects. "I think I might have an infection," he says. You admit him to the hospital and get an ultrasound which shows a complex fluid collection. Aspiration shows gram negative rods. Unfortunately at that time, he says, "I want to leave. I'm not going to stay. Just give me some oral antibiotics."

Challenge: What is the antibiotic of choice here? What might the organism be?

Image is in the public domain, from Wikipedia.

SummerTop

2011-05-05T09:00:00.000-07:00

You are in Uganda doing an international elective and you see the patient shown above. He comes in because of the painful lesion on his shoulder which he got while traveling through warm shaded forests in a large blue van (with open windows). On examination, the lesion is rubbery, painful, and indurated. You are unsure what it is and tell the patient to return in a week.

In a week, the patient presents again with intermittent headaches, fevers, malaise, and arthralgias. On exam, the patient has soft painless posterior cervical lymphadenopathy and splenomegaly.

Challenge: The diagnosis is lethal if untreated, so you better know what it is before it progresses to the next stage. (What's the next stage?)

Image is in the public domain.

Hard as a...

2011-05-02T09:00:00.000-07:00

A male infant presents with fatty, foul smelling diarrhea, poor growth (<3rd percentile for height, <3rd percentile for weight), and recurrent infections. His bowel movements are pale, greasy, and voluminous though with time, this symptom may resolve. He also keeps presenting with pneumonias and otitis medias. Labs show a pancytopenia as well as a low trypsinogen level. A sweat test is negative. A bone marrow biopsy shows hypocellular marrow. Full examination shows skeletal abnormalities such as metaphyseal dysostosis, thoracic dystrophies, and osteopenia. Notably, his parents are tested for the disorder he has and they are both found to be carriers of the genetic mutation. Down the line, the patient is at higher risk for myelodysplastic syndrome and AML.

Challenge: What's your diagnosis?

The Price is Right

2011-04-28T09:00:00.000-07:00

Challenge: Tell me about this EKG.

Image is shown under Fair Use.

Gardasil

2011-04-25T09:00:00.000-07:00

Challenge: Find the 3 mistakes in the following paragraph:

Gardasil is a quadrivalent HPV vaccine that targets HPV 16 and 18 which cause all cervical cancer as well as HPV 6 and 11 which cause 90% of genital warts. It is most effective prior to sexual debut. The Advisory Committee on Immunization Practices recommends that HPV vaccination be offered to women between age 11-12 as well as catch-up vaccination for women 13-26. It should not be offered to pregnant women because of teratogenicity noted in clinical trials. The vaccine has also been FDA-approved for use in men, and a clinical trial showed decreased anal intraepithelial neoplasia and cancer in men who have sex with men. Lastly, women who receive the HPV vaccine prior to sexual debut do not need to have cervical screening until age 25.

Image shown under Creative Commons Attribution Share-Alike License.

Cabbage

2011-04-21T09:00:00.000-07:00

Inspired by the prior post on attack plants, this one is called cabbage. One week after an obese 60 year old gentleman gets a coronary artery bypass graft, he develops a temperature to 38.3 and pulse of 102. He complains of worsening sternal chest pain. The cross-covering intern checks a troponin, which is negative, and brushes off the fever, saying it's atelectasis. But you're not so sure - when you go examine the patient, you note purulent drainage around the median sternotomy site. When you auscultate the heart, you note a crunching sound that occurs with the heart beat. Palpation has a "Rice Krispie" feel. The patient's past medical history includes diabetes which has not been well controlled since his surgery.

Challenge: What's the clinical diagnosis? Blood cultures are positive for what organism?

Image is in the public domain, from Wikipedia.

Attack Plants

2011-04-18T09:00:00.000-07:00

Clue: "Leaves of three, let them be."

Clue: The munchies.

Clue: Fuga Demonum.

Challenge: Identify these plants!

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

*Note: I am out of the country so answers may be later than usual (which I know are pretty late anyway).

"My Mom Told Me..."

2011-04-14T09:00:00.000-07:00

You see a patient who says, "my mom told me I was allergic to penicillin." You brush it off until he says, "my throat swelled up, I lost consciousness, I had whole-body hives, and I spent a week in the pediatric intensive care unit." Eeek! Now, you had wanted to use a cephalosporin, but I guess you'll have to use aztreonam (the first molecule shown).

Challenge: Unfortunately this is a clinical pearl that you either know or don't know. Aztreonam has a similar side chain to the beta-lactam drug shown in the second picture. If the patient has a specific allergy to this antibiotic, he should not get aztreonam. What is it?

Both images are in the public domain, from Wikipedia.

History of Medicine

2011-04-11T09:00:00.000-07:00

In the history of medicine, a Dutch pediatrician recognized an association between a particular disease and historical events. Patients with the disease (most often age 10-40) present with bulky foul-smelling steatorrhea and flatulence. However, during food shortages in the Second World War, patients' symptoms improved. After the war, the symptoms resumed.

Challenge: This disease was possibly first described by Aretaeus from Cappadocia in 2 AD. Do you know what it is?

Image is shown under GNU Free Documentation License, from Wikipedia.

Just Dance

2011-04-07T09:00:00.000-07:00

A 10 year old previously healthy girl presents with insidious changes in her behavior. She starts performing worse in school and has emotional changes with easy crying, irritability, and inappropriate laughter. This is followed by distal movements of the hands: rapid, irregular, nonstereotypical jerks that are continuous while the patient is awake but improve with sleep. The involuntary movements are generalized. You also note facial grimacing and fasciculations of the tongue. There is loss of fine motor control in addition to weakness and hypotonia. When you shake the patient's hand, you note that the pressure of the patient's grip increases and decreases continuously and capriciously. When she talks, her speech is "jerky" with sudden changes in pitch and loudness. An LP is performed and all studies are normal.

Challenge: This disease has decreased in incidence in Western countries, but you recognize it and listen closely to the heart because your presumed diagnosis is...what?

Image is in the public domain, from Wikipedia.

Unseen

2011-04-04T09:00:00.000-07:00

A G1P0 woman has an illegal abortion done on the streets. Several days later, she presents to the emergency department with high fever, chills, malaise, and abdominal pain. Vaginal discharge is both bloody and purulent. On physical exam, her heart rate is 120, respiratory rate 25, and she has low abdominal tenderness. A boggy, tender uterus with a dilated cervix is palpated.

Challenge: After stabilization, what is the medical and surgical management of this condition? What antibiotics would you choose?

Cedilla

2011-03-31T09:00:00.000-07:00

You are doing telemedicine and get these pictures from patients in Turkey. Patients are 20-40 years old and have recurrent painful lesions shown above. HSV is negative. They tend to be extensive and patients can have multiple lesions. For some patients, the pain is so bad they can barely eat anything. Yet the ulcers heal by themselves within 1-3 weeks.

Some patients get genital HSV screening too because they complain about the same lesions on the scrotum and vulva; often, these even lead to scarring. When doing a thorough skin exam, there are many varied lesions which can be acneiform, papulo-vesiculo-pustular, pseudofolliculitis, nodules, erythema nodosum, superficial thrombophlebitis, pyoderma gangrenosum, erythema multiforme, and palpable purpura. If you prick the skin with a needle, a pustule-like lesion or papule may form.

Eye abnormalities are also common, involving bilateral episodic uveitis, occasionally with purulence in the anterior chamber. Rarely, neurologic involvement may cause focal deficits. Some people present with hemoptysis. Others have recurrent DVTs. Most patients have a nonerosive asymmetric nondeforming arthritis of the knees, ankles, and wrists.

Challenge: What's your diagnosis?

Image shown under Fair Use.

Current Events

2011-03-28T09:00:00.000-07:00

You are participating in international relief efforts abroad as a result of natural disasters. Patients come in with multiple exposures. Those who've been exposed within several hours present with anorexia, apathy, nausea, vomiting, diarrhea, fever, tachycardia, and headache. Some people die immediately from fever, hypotension, coma, and severe vomiting. Others present with neurologic deficits and have disorientation, confusion, loss of balance, seizures, papilledema, ataxia, and decreased reflexes.

Those who were exposed 5 days ago have crampy abdominal pain, diarrhea, nausea, vomiting, and GI bleed. In weeks to months, patients expect neutropenia, thrombocytopenia, and anemia.

Challenge: What was the exposure?

Image is in the public domain.

Harder

2011-03-24T09:00:00.000-07:00

The cases get harder!
These images are from children under the age of 5 with symmetric sudden eruptions of raised lesions, mostly on the cheeks, buttocks, and extensor surfaces of forearms and legs. The lesions were preceded by an upper respiratory or gastrointestinal illness. The lesions do not go away and last for weeks. Itchiness varies. Some patients have lymphadenopathy; some have elevated liver function enzymes. The lesions usually spontaneously resolve after weeks.

Challenge: What's your diagnosis?

First image is in the public domain. Other three images shown under Fair Use.

Taking A Day Off

2011-03-21T18:51:00.000-07:00

I'm taking a quick break today from a new case as things have been incredibly busy. I'll be back with a new case on Thursday. Meanwhile, I wanted to direct you to The Atrium Magazine, a new, innovative web-based resource created by a friend of mine at Yale University. My cases of the day are actually featured here:
http://www.atrium-magazine.com/2011/03/cases-of-the-week-i/

Mickey Mouse

2011-03-17T09:00:00.000-07:00

Challenge: This pattern of findings is consistent with what kind of disease?

Images shown under Fair Use.

Fowl Play

2011-03-14T09:16:00.000-07:00

You are the anesthesiologist for a neurosurgery for a patient with cranial synostosis. The patient is in Fowler's position. You DJ the iPad music, glance at the news of the day, and listen to blips of the heart (you can YouTube this). Suddenly the patient becomes immediately hypotensive and tachycardic. You note the patient's JVP suddenly rises. You turn down the music and hear a sucking noise. You send a stat ABG from the radial art line which showed hypoxemia and hypercarbia. The EKG on the monitor shows peaked p waves, non-specific ST changes, and sinus tachycardia. You start fluids wide open, prepare vasopressor support, and ask the neurosurgeon to place the patient into Tredelenberg.

Challenge: What happened?

Image from www.medtrng.com, shown under Fair Use.

The Mean Folk

2011-03-10T09:00:00.000-08:00

This adolescent woman has tried multiple topical therapies without relief and wants to switch to a systemic therapy. Your preceptor asks you to counsel her on safe sexual practices.

Challenge: Why?

Image shown under Fair Use.

Abx

2011-03-07T16:04:00.000-08:00

An older gentleman comes in with a productive cough and shortness of breath. By nursing protocol, he gets an EKG, shown above. You make a clinical diagnosis of community acquired pneumonia and write a prescription for moxifloxacin. There are no TB risk factors. Your attending, aghast, says that's not appropriate!

Challenge: Why?

Image shown under Fair Use.

P.S. Sorry, I was late with this post as I accidentally put it on my regular blog.

Suicidal Ideation

2011-03-03T09:00:00.000-08:00

A 25 year old man is brought in by EMS. A suicide note and an empty unlabeled bottle are found next to him. The patient is minimally arousable, hyperthermic, and flushed. Pupils are dilated. Minimal bowel sounds are heard. A Foley catheter is placed and 400cc urine comes out. Fingerstick glucose, acetaminophen, and salicylate levels are fine. Here's an EKG:

You recognize what's going on and push sodium bicarbonate. The EKG changes before your eyes to:

Challenge: What happened?

Images are shown under Fair Use.

Teardrop

2011-02-28T09:00:00.000-08:00

This finding is seen in a construction worker who had acute vision loss at work. On exam, you note that this pupil constricts when light is shined on the opposite eye, but there is less constriction when light is shined on the affected eye. When fluorescin is placed, you note this (they are different pictures, but imagine the top of the green to be the top of the teardrop pupil):

Challenge: Where's the injury? What happened?

Images shown under Fair Use.

Masquerade

2011-02-24T09:00:00.000-08:00

This woman comes in with patchy light to dark brown hyperpigmentation of the cheeks, forehead, and upper lip. This condition is more commonly seen in Asians, African Americans, and Hispanics. It is related to sun-exposure.

Challenge: This common condition affects 75% of women who are...what?

Image shown under Fair Use.