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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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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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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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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?

Harlequin

An adult patient develops severe hypoxemia from a pneumonia and goes into cardiac arrest. He is successfully resuscitated with the machine shown above. The following day, it is noted that a sat probe on his right forefinger and a sat probe on his ear reads 75% whereas a sat probe on the toe reads 98%. He does have a right femoral arterial cannula and an ABG drawn there reads a PaO2 of 150mmHg. However, when you do a fresh ABG stick from the right radial artery, the PaO2 is 40mmHg.

Challenge: What machine is he on?

Image is in the public domain.

Diagram

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

Challenge: What is it?

What's the Surgery?

A middle aged patient presents with acute onset persistent severe epigastric abdominal pain. The pain radiates to the back and is relieved by sitting up or bending forward. It is accompanied by nausea, vomiting, and dyspnea. Exam shows diffuse tenderness, abdominal distension, and hypoactive bowel sounds. He is admitted to the hospital for supportive management.

Unfortunately, overnight, he develops fever, tachypnea, tachycardia, and hypotension. He is transferred to the critical care unit and started on norepinephrine and vasopressin for septic shock after adequate fluid resuscitation. A CT is shown below:

He has acute kidney injury and acute respiratory distress syndrome requiring intubation, but over the next few weeks, he is stabilized and eventually extubated. Four weeks after the initial presentation, he still has chronic low grade fever, nausea, lethargy, and inability to eat.

He then undergoes surgery even though the mortality rate is somewhere between 4-25% and complications include intra-abdominal fluid collections, bleeding, fistulas, incisional hernias, poor glucose control, and need for enzyme therapies.

Challenge: What was the operation?

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Refresher IV

This disease represents the rule of 2's: it occurs in 2% of the population, the male:female prevalence is 2:1; it occurs within 2 feet of the ileocecal valve, and it can be two inches in length.

Challenge: What is the diagnosis?

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White Bile

A young woman presents with right upper quadrant abdominal pain. Ultrasound shows a stone in the cystic duct. You take her to the operating room for a cholecystectomy. You find a quite distended gallbladder, but what surprises you is that when you aspirate fluid from the gallbladder, it is colorless and mucoid.

Challenge: What's the diagnosis?

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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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Barium

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

Challenge: What do you see?

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Phantom

Here's a great case! This blood smear is from a patient with massive hemolysis. In fact,the laboratory called because routine chemistries are not working correctly and they cannot cross-match the blood. The patient initially presented with multiple knife wounds in a fight over black tar heroin (he also does skin popping). He had severe pain at the site of the injuries and was admitted to the hospital for monitoring, but over the last 24 hours, has become quite ill. He was transferred to the intensive care unit with tachycardia, fever, and shock. He is developing renal failure. The skin over his injuries has developed a bronze appearance with some red and purple discoloration. The skin is tense and exquisitely tender. There are some bullae present.

Challenge: What's the diagnosis?

Broken

This frontal cervical radiograph is from a patient presenting with headache. She has a history of obesity, pre-diabetes, normal pressure hydrocephalus, and asthma. She's had several surgeries in the past.

Challenge: Look closely at the radiograph; what do you see here?

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Marathon

A 35 year old marathon runner comes to you because of foot pain. The pain is mostly in the medial arch of her foot. There is point tenderness over a bony prominence inferior and anterior to the medial malleolus. Imaging is shown above.

Challenge: What's your diagnosis?

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Post-Op Complications

A 72 year old man with obesity and COPD use on chronic steroids undergoes an open laparotomy, colon resection, and end-ileostomy for colon cancer. A year later, he develops a mild abdominal discomfort. CT is shown above.

Challenge: What do you see above?

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Glow in the Dark

You are in a emergency exploratory laparotomy for a patient who developed peritonitis. Half way through running the bowel, the surgeon asks the anesthesiologist to give fluorescein. He then asks the circulator to pull this device out of the closet.

Challenge: What is it and what's he looking for?

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Burrito

Challenge: What's being shown here?

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Systems

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?

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Lodestone

"Supine and upright views of the abdomen show an elongated rod shaped radioopaque structure measuring maximally 12cm in length and about a centimeter in width which lies obliquely within the stomach. It has 8 dense radioopaque elements. The bowel gas pattern is normal. The osseous structures are intact."

If only one of these were ingested, it wouldn't be so bad. But this child needed endoscopic intervention to remove these things.

Challenge: What are they?

Both images shown under Fair Use.

Comes in Yellow and Black

A few days post-op from a laparoscopic cholecystectomy, a patient continues to have pain, fever, abdominal distension, ileus, and jaundice. Unfortunately, the drain placed after the lap chole was pulled out when the patient was agitated. The patient gets further imaging and a procedure shown below.

Challenge: What's shown in the images above?

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