Mike and Ike

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

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...

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

Challenge: Tell me about this EKG.

Image is shown under Fair Use.

Gardasil

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

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

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..."

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

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

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.