A patient comes to you complaining of hearing loss. He says that ever since he "caught a cold which worsened his allergies," he feels like his hearing is muffled, almost like he's under water. He can "pop" his ears and then they sound normal for a while. On exam, you see that the tympanic membrane is retracted without moving properly.
Challenge: What's your treatment of choice?
Image shown under GNU Free Documentation License.
These biopsies are from a 60 year old gentleman who was admitted to the ICU for a severe COPD exacerbation. He has a known history of COPD, diabetes, and hyperthyroidism, was not taking his medications, and came into the emergency department with hypercarbic respiratory failure one week ago. He was intubated for airway protection due to altered mental status. He has been on high dose IV glucocorticoids for the COPD exacerbation.
You are evaluating a 50 year old smoker for lung resection for localized non-small cell lung cancer. Pre-operative pulmonary function tests include: FEV1 1.8 L, 75% of predicted, preoperative DLCO 90%, predicted post-operative FEV1 is 900mL or 45% of predicted.
A healthy 55 year old gentleman is scheduled for a laparoscopic cholecystectomy for symptomatic cholelithiasis. He has not seen a doctor in ages but is "otherwise healthy." He has never had surgery before. He takes five herbal medications for "general wellness." He has no allergies. He smokes marijuana daily, but does no other alcohol or drugs. His vital signs are all within normal limits. His Mallampati score is II, he has good neck range of motion, and his heart and lungs are normal on exam. Because of his age, a screening EKG is obtained and shown above. The EKG computer says "abnormal EKG."
These images are from a patient with a "vanishingly" rare disease which affects children and young adults (age<40). Although almost any bone can be affected, the shoulder girdle, pelvis, and mandible are most common. The lesion is nonulcerative but locally aggressive. You take a biopsy which shows no malignant cells but intraosseous proliferation of hemangiomatous or lymphangiomatous tissue. Osteolysis is present. The disease is not hereditary. Some patients present with pain, swelling, or a pathologic fracture, while others are asymptomatic. There are no specific laboratory findings.
Jaundice A starts at 3-5 days of life, peaking at 2 weeks. Total bilirubin levels are commonly >5 and mostly unconjugated. This is a relatively benign condition. Jaundice B starts at the first week of life in conjunction with weight loss and dehydration; it is seen more commonly in preterm rather than term infants.
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."
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.
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