Blue Devils

A 60 year old man with diabetes complicated by dialysis-dependent renal failure, mitral valve prolapse, benign prostatic hyperplasia, and dyslipidemia presents with fever, chills, night sweats, and a rash. Unfortunately, he can't give a really good history.

His temperature is 38.5 C, his blood pressure is 125/80, his pulse is 85, and his respiratory rate is 16. Physical exam findings are shown above. The second image shows painful nodules. The third image shows painless macules. Two separate blood cultures are positive, but the lab has not been able to determine the organism yet.

Challenge: What are the likely organisms?

Related Questions:
1. What does each image show?
2. What's the diagnosis?

All three images shown under Fair Use.

First-Second

You are on a medical mission in Africa where you take care of numerous children like the ones shown above. Height and weight are nearly normal for age. They all have anorexia, a palpable liver, pitting edema, hair that falls out, and dry atrophic peeling skin.

Challenge: What is your diagnosis?

Both images are in the public domain.

Happy St. Patrick's Day

A 60 year old man presents with a gradual onset of difficulty walking which has worsened over the last few weeks to months. He feels weak, unsteady, and uncoordinated in his legs. He's also recently developed poor coordination of the arms, dysarthria, and intermittent diplopia and blurred vision. His past medical history is only significant for a few episodes of alcoholic hepatitis and a remote appendectomy. His social history is significant for being a heavy drinker for 25+ years.

On exam, he appears malnourished. Mental status and cognitive function are normal. On his cranial nerve exam, visual fields and acuity are intact, fundoscopic exam is normal, pupils are round and reactive to light, extraocular movements are intact, facial sensation is intact, muscles of mastication and muscles of facial expression are symmetric and strong, hearing is grossly intact, palate is midline and moves fully, head rotation and shoulder shrug are strong, and tongue movement is symmetric. He has slow, slurred speech and a coarse rhythmic 3-5 Hz postural tremor of the fingers. He has ataxia of stance and gait. He cannot do tandem walking. Heel-knee-shin testing is grossly abnormal, and finger-nose testing is mildly abnormal. His blood alcohol level is 0.

Administration of thiamine does not reverse this disease.

Challenge: Localize the lesion! What's your diagnosis?

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

Hormones

A 25 year old woman who is 10 weeks pregnant presents with fatigue, nausea, vomiting, and nocturia. These have all had gradual onset over the last few weeks. Her primary care doctor sends off a battery of labs and finds that serum TSH is low, serum total T4 and T3 are both elevated, and free T3 and T4 are at the high end of normal.

Challenge: What is the most likely cause of these findings?

Overzealous

This patient came in with a GCS of 7. His chest X ray on arrival was normal. The emergency room physicians fussed around with him a bit, and now he looks like this.

Challenge: What's the cause?

Image is shown under Fair Use.

Black and White

Challenge: Anatomically, where is the abnormality in this PA CXR?

Image shown under Fair Use.

Deep End

Since I'm on radiology, this week will be x-ray week.

This patient was brought into the emergency department due to trauma.

Challenge: What's the diagnosis? What kind of trauma did the patient sustain?

Image shown under Fair Use.

Jellyfish

A 25 year old man swimming off the coast of Northern Australia feels a sharp mildly painful sting. He returns to shore, and 30 minutes later, begins to feel severe generalized back, chest, and abdominal pain, nausea, vomiting, sweating, and agitation. Physical exam shows hypertension and tachycardia. About 12 hours later, he develops myocardial injury and pulmonary edema. The tiny jellyfish shown above, about 2cm in diameter with long tentacles, was identified as the culprit.

Challenge: This syndrome has a particular name; what is it?

Image is shown under Fair Use.

700,000 Surgeries/Year

This image from a 40 year old man shows a shaved surgical site at the location of the pathology. He initially presented with heaviness or dull discomfort in his pelvis worse with straining, lifting, and prolonged standing. This is relieved by lying down. He noticed this bulge in the right groin, and it is more pronounced with coughing.

Challenge: What is the diagnosis?

Image is in the public domain.

Misnomer

I have a friend with these symptoms!

A 25 year old woman presents to your primary care clinic with foot pain while running. Normally, she is asymptomatic, but when she runs, she feels numbness, tingling, aching, and burning of the distal forefoot. The pain radiates from the metatarsal heads to the third and fourth toes. The symptoms are worse while running on hard surfaces and while wearing tight high-heeled shoes. On physical exam, you note tenderness in the plantar foot over the point noted in the diagram above. Compressing that area creates a "click" and reproduces the patient's symptoms.

Challenge: What's the diagnosis?

Image shown under Fair Use.