Car Insurance

You are the surgeon on call at midnight and you're getting antsy because there aren't any good cases going on. You troll through the emergency department looking for appendices to remove and wander into the CT scan just as this image comes onto the screen. You're in business! You glance at the CT requisition and it says "65 year old man, back pain, hypotension."

Challenge: You call the OR immediately and tell them a patient is coming up with what?

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Sports Physical

A 16 year old boy comes to you for a routine sports physical. He has no symptoms and is feeling pretty well. An adolescent HEADSS interview reveals that his parents are divorced but he gets along with both, he is a B+ student, he enjoys running and playing video games, he has tried alcohol but no other drugs, he is sexually active with one partner, and he has no suicidal thoughts. He has no past medical history and takes no medications. His family history reveals that a paternal grandfather died of heart failure at age 50, an uncle died of sudden death at age 25, and his father has unexplained dyspnea on exertion and chest pain though a recent coronary arteriogram was normal.

On exam, the patient's vitals are normal and he is in no acute distress. On cardiac exam, you feel a prominent left ventricular lift with a diffuse apical impulse. You hear an S4 along with a harsh crescendo-decrescendo systolic murmur best heard at the apex and left lower sternal border. The murmur radiates to the axilla and base. When you have the patient Valsalva, the murmur gets louder. When you elevate the patient's legs, the murmur gets softer. The carotid pulses are normal. The lungs are clear to auscultation bilaterally. The abdomen is benign. There is no cyanosis, clubbing, or edema. An EKG is taken in the office and shown below.

Challenge: What's the most likely diagnosis?

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Tired

A 45 year old man presents with fatigue, your favorite chief complaint. The fatigue has been getting worse over the last few months. He's just been so sleepy during the daytime, especially when doing boring, passive, or monotonous activities. He even admits to dozing off while reading, watching television, and driving. Last week, he fell asleep and began snoring at church which embarrassed him. When you delve deeper, it's not that he doesn't have energy, he just falls asleep. Sometimes at night, he wakes up with a sensation of choking, gasping, or smothering. He also complains of a dry mouth while asleep and often has restless, fitful sleep. He has a past medical history of obesity, hypertension, coronary artery disease, chronic renal insufficiency, type 2 diabetes mellitus, and GERD. Review of systems is positive for decreased sex drive, headaches in the morning, and poor concentration. He denies feeling depressed.

Challenge: With just the history, what's your diagnosis?

Hard

This patient also has fatigue, stiff joints, weakness, pain, sleeping difficulties, and skin discoloration.

Challenge: What's your diagnosis?

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Say Ahhh

The tongue shown here belongs to a 25 year old woman presenting to a primary care doctor. She recently got health insurance because of the new healthcare reform bill. Yay! She has no complaints. She is otherwise healthy, but had a lot of spontaneous recurrent nosebleeds in childhood. She takes no medications. She has a family history of embolic strokes (including one from a deep vein thrombosis in someone without a heart defect), recurrent GI bleeds, and cerebral abscess in every generation of her father's side. She does not smoke or do drugs, and she only drinks occasionally. She lives with her cat and works at the supermarket.

Her physical exam is normal except for the finding shown above and a rectal exam that is positive for occult blood in the stool. Because of that, you send some basic labs which show a microcytic anemia. Wow! This was totally unexpected. You just made an important diagnosis because more people have health insurance and can see a doctor due to the healthcare reform bill.

Challenge: This syndrome has two names, each of which has three words. What is it?

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Because I Could Not Stop for Death

A 35 year old woman presents with pelvic discomfort. She hasn't had a menstrual period in six weeks but yesterday began to have some vaginal spotting with mild suprapubic pain. She is sexually active with two partners. She has smoked one pack of cigarettes a day for 5 years and is a moderate to heavy drinker.

On exam, you note a closed cervical os. A urine pregnancy test is positive. An ultrasound shows a long, closed cervix with uterine size appropriate for gestational age.

Challenge: What "kind" of abortion is this?

Cornrows

A hair pull test shows fragmented hairs of varying lengths.

Challenge: What is the cause of this patient's hair loss?

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Meow

A 22 year old man is brought to the doctor by his roommate. The roommate has known the patient for years, but says about a year ago, the patient started acting weirder without any trigger. The patient would have episodes of not leaving his room, not talking, not responding, and not wanting to do anything. There have been 1-2 past episodes. About a week ago, the patient started acting in the same way. Indeed, the patient has a blank look on his face, responds to few verbal commands, but withdraws to noxious stimuli. The patient has no interest in his environment. He gives monotonous one-word responses to some questions. He displays no emotional range, and when asked, says he feels "bad." The roommate says the patient dropped out of community college a few months ago, has never held a job for longer than a month, and has almost no friends. Mental status exam shows poor attention, language, memory, and executive function. When you raise his left arm over his head and let go, he keeps it there even though the position is awkward. Yet when you move him in other ways, he seems to have purposeless resistance.

Challenge: What's the most likely diagnosis here?

Awful

This is a 3 year old boy with a history of nephrolithiasis who bites himself; his lower lip is mutilated and he has a wound on the dorsum of his hand. His tongue is spared. He has uncontrolled motor movements with action dystonia and baseline hypotonia. He also has delayed developmental milestones and mental retardation. Labs show a macrocytic anemia.

Challenge: What is this disorder? How is it inherited?

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No History

You are on your radiology elective and this chest X-ray is given to you. The clinical history box reads: "Patient in ED Bed 3. Have a nice day! -Craig."

Challenge: What's the finding? What's the likely clinical scenario?

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