Thief

A middle age man with known atherosclerotic disease presents with left arm claudication, fatigue, coolness, and tingling. He gets dizzy when he exercises the arm. On examination, you note the left arm has a 15mmHg lower systolic pressure than the right arm. Palpation of both radial pulses shows a decreased amplitude and delayed arrival on the left side.

Challenge: If blood is flowing in the wrong direction, what syndrome is this?

Out of Crime

This smear is seen from a woman who had an uncomplicated UTI treated with an oral agent 100 mg twice daily for 7 days. This agent is only used for E coli UTI.

Challenge: What caused the finding shown in the blood smear?

Image shown under fair use.

Emergency Ultrasound

*Note: I originally put up a different case for today but decided to change it to a pregnancy-related case since, of course, it's labor day.

A 33 year old woman is BIBA (brought in by ambulance) for hypovolemic shock. You note a significant ascites, hyponatremia, hyperkalemia, and pleural effusion. She says, "I've been trying to get pregnant." You get an ultrasound:

It might look like PCOS (polycystic ovarian syndrome) but your attending suggests it is something more serious.

Challenge: What does your attending think?

Related Question:
1. How does wanting to get pregnant fit into this picture?

Image shown under fair use.

He Named It, Then Died of It

A 60 year old man presents to your emergency department with epigastric pain that radiates to the back. He says that the pain is alleviated by sitting up or leaning forward. It is worse 15-30 minutes after eating. Sometimes, he also gets nausea and vomiting. He is a heavy drinker and smoker. As you ask him about other symptoms, he mentions loose, greasy, foul smelling stools. He went to a free diabetes clinic last year and was told he had diabetes. He had several episodes of hypoglycemia in which he came to this ER but after being treated, left AMA (against medical advice).

In 1865, a physician documented an odd pattern of traveling thrombosis. He described a patient who had recurrent migratory thrombosis of the superficial veins in odd sites like the arms and chest. You notice that in this patient. He looks pretty ill, and when you ask him further, he says he's lost a significant amount of weight.

Challenge: Imaging studies are necessary to confirm, but what's your top diagnosis?

Related Questions:
1. The first and second paragraphs, though related, suggest distinct diseases (ie. the first is a risk factor for the second). What are they?
2. What's the pattern of traveling thrombosis called?

Help

A pregnant woman at 32 weeks gestation presents with abdominal pain, nausea, vomiting, and malaise. She has mid-epigastric and right upper quadrant tenderness. Exam shows blood pressure 150/90 and proteinuria. Labs show platelets at 80,000, serum LDH 800, total bilirubin 2.0, and serum AST 120.

Challenge: What is your diagnosis?

Image shown under fair use.

Sympathy

In an unfortunate industrial accident, a patient's right eye is lacerated with a sharp instrument. He loses function of that eye, but it is not removed. Several years later, the other eye is diagnosed with uveitis. Weird.

Challenge: What's the diagnosis?

No Longer Seen

A young child presents with non-specific symptoms of nausea, vomiting, headache, excitability, delirium, and combativeness. It slowly progresses to coma. The only other remarkable finding was a recent chickenpox infection that the parents treated with this:
Challenge: What is your diagnosis?

Image is in the public domain.

Derivative

A 6 year old child presents with a puffy face and puffy legs. His albumin is 2.8 g/dL (low).

Challenge: What's the most likely diagnosis?

Image shown under fair use.

Ictal

A patient presents to your clinic with moderate weakness of the left hand. It had a sudden onset and the patient is afraid he had a stroke. The history of present illness is significant for an episode earlier today of loss of consciousness. He says that his wife noted involuntary left hand movements at that time.

Within a few hours, the patient's weakness resolves.

Challenge: This condition was first described by a British physician in 1849. What is it?

Brobdingnagian

A 72 year old man complains of pain and stiffness in his neck, shoulders, and hips. He also gets some pain in his jaw when eating. Speaking of pain, he's noticed a recent new headache. Here's a biopsy:

Challenge: What should this gentleman get before he leaves your office today?

Related Questions:
1. What is the pain in the neck, shoulders, and hips called?
2. What is the feared complication of this disease?
3. What lab test would you like to get?

Images shown under fair use.