Private Practice

A 30 year old woman presents to your clinic because she's lost her appetite recently. She feels really tired all the time; the fatigue gets better when she rests, but it's like she has no energy. She has general weakness and has had some weight loss. You assess for depression, but it seems to be more than that. She has nausea and occasional vomiting, abdominal pain, diarrhea, and constipation. She's felt dizzy on occasion. She says she enjoys laying out in the sun cause she tans really easily. On exam, you find orthostatic hypotension and notice this:

Challenge: What's the diagnosis?

Related Question:
1. What's seen on the image?

Image shown under fair use.

One Liner

When you see a 10-hour-old Caucasian newborn with severe vomiting and abdominal distention who has not yet passed any stool, you confirm your diagnosis by licking the baby.

Challenge: What is the diagnosis?

Related Questions:
1. What is the vomiting, abdominal distension, and absence of stool called?
2. What did you find when you licked the baby?

Note: I decided not to take a suggestion to name this case "Lollipop."

Need to Know

You are examining a 60 year old obese female patient two days after a hip replacement. She is a 50 pack-year smoker currently being treated for breast cancer. As you are examining her, she suddenly becomes short of breath. Her respiratory rate increases to 24 and heart rate increases to 110. In between breaths and coughs, she says, "it hurts when I breathe in." You hand her a tissue and when she coughs again, you see there is blood on the tissue.

She gets an immediate CT angiogram. The abnormalities are shown by the arrows.

Challenge: What is your diagnosis?

Related Questions:
1. What is the significance of the hip surgery?
2. What is the significance of the lung cancer and obesity?

Image shown under fair use.

Van Beethoven

A 30 year old man presents to your emergency department complaining of severe pain in his mouth and an inability to swallow. He leans forward as he talks. He complains of a stiff neck and drooling. You note a fever and stridor on pulmonary exam. As you look into the oral cavity, you see that the tooth shown below has partially come out of the gums in the lower right jaw. There is swelling and stiffness of the jaw and sublingual space.

Challenge: What's the diagnosis?

Related Questions:
1. What kind of tooth is that?
2. What's stridor?

First image in the public domain.

Med Student Consult

You are just beginning your second year of med school when your cousin calls you. "You're a doctor, right?" Before waiting to hear your fervent denial, she continues, "I'm a little worried, and I'm wondering if you can help me. My fingers and toes really hurt, they feel so cold. I haven't been doing anything unusual though, so I don't know why. They were really white the other day, and now they're bluish. I'm really worried! They occur in both my hands and both my feet. I don't know what to do."

You tell her to calm down. Your cousin is about 21 and just broke up with her boyfriend. She goes to school in Wisconsin. She is a smoker and has pretty bad migraines.

Challenge: What is your diagnosis?

Image in public domain.

Eggs in One Basket

A 30 year old woman presents to your fertility clinic because she is having difficulty getting pregnant. As you take a focused history, you find that she began having periods at age 14 but her cycles have always been irregular, infrequent, and unpredictable. She had severe acne when she was young and has had an abnormal amount of hair on the upper lip, chin, around the nipples, and along the linea alba of the lower abdomen. When you take an ultrasound of her ovaries, you see this:

Challenge: What is your diagnosis?

Related Questions:
1. What is the hair finding called?
2. What is seen on the image?

Image shown under Fair Use.

Happy New Year's

You pull the short straw and get stuck with the New Year's Eve shift. A van pulls up to the curb of your ER and rolls a body out onto the doorstep before driving away. The patient looks like he's in his early 20s. He stumbles around looking pretty unsteady. You can't really elicit a history from him; his speech is slurred and he seems to have some memory impairment. His eyes look like this (click on image to make it move!):

With a big sigh, you run tests and rule out head trauma, hypoxia, hypothermia, hepatic encephalopathy, and other metabolic disarrangements. There is an elevated osmolal gap.

Challenge 1: What's the diagnosis? What's seen on the image?

Two days later, a different patient is brought into your ER by the police; he was seen on the streets shouting about the ninjas attacking him and vomiting. He looks to be in his mid-30s and he is very disoriented. He can only tell you about the pink elephant in the room, and any attempt to calm him just riles him up more. On exam, you find tachycardia, tachypnea, hypertension, a low grade fever, and marked diaphoresis. One of the bystanders comments that he's "seen this man before - he's always drinking and panhandling for more booze."

Challenge 2: What's the diagnosis?

Image shown under GNU Free Documentation License.

X Marks the Spot

On your last day of pediatric preceptorship, you see a 13 year old boy complaining of "weird spots" on his lower abdomen and butt. He also says that since a few years ago, he often has burning pain in his hands and feet, especially when he has a fever. This pain radiates proximally and is sometimes relieved with rest. On exam, you notice the following two findings (the second is seen by the slit-lamp):

When you ask the patient about his family history, he tells you that his uncle on his mother's side recently received a kidney transplant. This uncle also has skin lesions and extremity pain.

Challenge: What is your diagnosis?

Related Questions:
1. What is the skin finding?
2. What is the eye finding?

This case written by Kate Dinh.
Both images shown under fair use.

It's Not...

This woman storms into your office, absolutely outraged (or, by the blush on her cheeks, embarrassed?). She shouts, "The other doctor accused me of having syphilis! He said a lab test even confirmed it. I can't possibly have syphilis. I haven't slept with anyone in years."

Challenge: Explain.

Case idea contributed by Alex Penn.
Image is in the public domain.

Merry Christmas

A 14 year old boy presents to your clinic with a swollen and painful left knee. He said it was preceded by stiffness and followed by a warm sensation, then acute pain. There is no history of trauma; the boy just played a basketball game. You send off labs and get a normal platelet count and PT, and a prolonged aPTT. A mixing test corrects the abnormality. You send off a specific factor VIII assay; it's normal.

Challenge: What's the next most likely diagnosis? This disease has another name; who was it named after? What is its transmission?

Related Questions:
1. What's the differential for a normal PT and a prolonged aPTT?
2. (Review) A normal aPTT and a prolonged PT?
3. (Review) A prolonged PT and aPTT?