ERCP

Although at presentation, most patients with this disease are asymptomatic, this ERCP is from a patient with inflammatory bowel disease and an elevated alkaline phosphatase. She initially presented with fatigue and pruritis, though other symptoms include fever, chills, night sweats, and RUQ pain. Alkaline phosphatase is remarkably elevated, though AST/ALT are less than 300. She also has hypoalbuminemia, hypergammaglobulinemia, increased serum IgM. Antimicrosomal antibody is negative though a smattering of other autoimmune markers are positive.

Challenge: What's your most likely diagnosis?

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Debunked

This 2 year old child has not yet talked but is able to do this. In fact, this is all he likes to do. When you try to interact with him, he does not make eye contact. "He likes to play alone," the parents say.

Challenge: That's all you really need to suggest a diagnosis of what?

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I Saw This Mismanaged

A 60 year old patient comes in with bradycardia in the 40s. He doesn't have the typical symptoms of bradycardia; he doesn't feel weak and hasn't had syncope, but instead he complains of headache, nausea, and vomiting. His other vital signs include a temperature of 37C, a blood pressure of 170/90, a heart rate of 42, and an irregular respiratory rate ~8. I saw this case mismanaged because the diagnosis wasn't recognized.

Challenge: Who is the man shown above and how is he related to this case?

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Water Under the Bridge II

This is the second part to a two-part case (scroll down to see the first part).

Unfortunately, the patient described in the last case fails to follow up with a doctor. He finally presents with intractable coughing and recurrent pneumonias. He is intubated and a percutaneous gastrostomy tube is placed for nutrition. He continues to get recurrent pneumonias until finally a diagnostic procedure is done involving methylene blue in the tube feeds.

Challenge: What is the diagnostic procedure? What do you expect?

Water Under the Bridge I

This is the first part of a two-part case.

You are doing an away rotation in China where many people smoke, drink, and eat very little fruits and vegetables. You see a patient with longstanding GERD and gastritis that has been untreated for 20 years. He is presenting with weight loss. Upon further inquiry, you find that he has solid food dysphagia as well as anorexia. Apples, meat, hard-boiled eggs, and bread seem to "stick" in the patient's throat. The patient says his voice has become hoarse.

Endoscopy shows this at the gastro-esophageal junction:


Challenge: What is the diagnosis?

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Sounds Like the Last Case

A 30 year old woman presents with pain on urination. She is empirically prescribed a course of trimethoprim/sulfamethoxazole but her dysuria persists. On examination, you note painful genital ulcers and tender local inguinal lymphadenopathy. There are multiple pustular vesicles and ulcers that arise after a 4 day incubation period and last 2-3 weeks. In addition, she complains about fever, headache, malaise, and myalgias.

Challenge: What's the most likely diagnosis?

Hermes

The gentleman shown above has an intention tremor, gingivitis, excessive salivation, excitability, insomnia, irritation, and shyness. He is likely to die of an interstitial pneumonitis. His exam shows swollen salivary glands.

Small kids with this disease develop a body rash, swelling, and irritation of palms and feet followed by desquamation, irritability, photophobia, fever, and insomnia.

Other syndromes include peri-oral paresthesias, malaise, constriction of the visual fields, deafness, and ataxia as well as nephrotic syndrome.

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Two Step

A 70 year old smoker with HTN, hyperlipidemia, and diabetes presents with severe crushing chest pain and calls 911. The EKG en route is shown above. He is given an aspirin, nitroglycerin, and oxygen. On arrival to the emergency department, he is hemodynamically stable. On his way to the cath lab, he suddenly becomes profoundly hypotensive. Your exam reveals no new murmur, clear lungs, and distant heart sounds. Within a minute, he has a PEA arrest and dies. An autopsy is shown below.
Challenge: What happened?

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Rhythm and Blues

Challenge: What's the rhythm?

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