Dreaded II

This 55 year old man with Peutz-Jeghers syndrome underwent an ERCP for nausea, vomiting, and abdominal pain. The arrow shows the common bile duct. The arrowhead shows the pancreatic duct.

Challenge: What's your diagnosis?

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Dreaded I

This CT scan is taken from a 50 year old African American man with diabetes, smoking, obesity and a history of partial gastrectomy. He initially presented with asthenia, weight loss, anorexia, insidious gnawing epigastric pain, jaundice, and dark urine.

Challenge: What's the diagnosis?

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Bile

All these children had their diagnosis made on liver biopsy as infants. They have tried or are taking ursodiol, rifampin, and cholestyramine. Some are better by school age, though a small minority go to liver transplantation. When getting a liver, it's important for the anesthesiologist to know that they may have cardiac anomalies, especially peripheral pulmonic stenosis. Most have unusual vertebrae as well. Some are short, have renal disease, or have pancreatic insufficiency.

Challenge: What's the common underlying disease?

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Breaking Big Tobacco

As a wonderful family physician, you convince one of your patients to quit smoking. You transition them to a medication for smoking cessation which enhances CNS noradrenergic and dopaminergic release. You tell the patient to start the medication a week before their quit date and to take it for three months. The side effects are insomnia, agitation, dry mouth, and headache.

Challenge: What's the medication?

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Nourishment Barrier

A 49 year old male farmer has been bothered for years by a migratory arthralgia of the large joints. More recently, he's developed diarrhea, weight loss, abdominal pain, and severe wasting. His family has noted that he's been more confused as well. But most recently, he's developed a curious continuous rhythmic movement of eye convergence with concurrent contractions of the muscles of mastication. On exam, he has a vertical gaze palsy and a cerebellar ataxia. Labs rule out thyroid disease, connective tissue disease, inflammatory bowel disease, and HIV/AIDS. Labs show an elevated INR.

The patient undergoes endoscopy with small bowel biopsy, shown below.

Challenge: What's your diagnosis?

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Bates

A 20 year old G1P1 woman presents two weeks postpartum with bizarre behavior. According to the husband, she has not been sleeping at all and has started "hearing and seeing things." She also believes her child is an incarnation of an evil deity; at first, the husband thought it was a joke, but she seems completely serious. She has rapid mood changes, anxiety, and irritability. She has no history of any medical or psychiatric disease, though there is a family history of bipolar disorder. The husband asks if this could be a manifestation of thyroid disease.

Challenge: You hospitalize this woman for a medical emergency - what?

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Grit

A 60 year old woman undergoes a multi-level lumbar discectomy for lumbar spinal stenosis. The surgery goes as expected and the patient is brought to the post-anesthesia care unit. In recovery, the patient starts complaining of severe left eye pain. "I can't open my eye," she says, "because it feels like grit or sand is in it." Her visual acuity is roughly baseline. A fluorescein stain is shown below.

Challenge: What's your diagnosis?

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Sunny Side Up

An 18 year old previously healthy woman has several months of an enlarging abdomen; one day, she presents with acute onset severe abdominal pain. She is found to have an ovarian mass which is removed. This is the histopathology:

The gross pathology is shown below. The tan, fleshy portion (green arrow) makes the diagnosis.

Challenge: What is it?

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Look Closely

Challenge: What's the rhythm here?

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Sight

An 80 year old man who never sees a doctor is brought in by his children because of "weird" behavior. He has been running into doors, falling, knocking things off tables, and unable to locate anything. He says there's nothing wrong with his vision and that he's "just fine." When you show him three fingers, he says he sees two. When you do confrontation of his visual fields, it seems random which fingers he says are wiggling. When asked what color shirt his daughter is wearing, he says "red" when she is wearing a green shirt. He seems to genuinely believe what he is saying. A fundoscopic exam is shown above. An MRI makes the diagnosis.

Challenge: What's the diagnosis?

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