I Have this Disease

Ever since a child, this patient has had this disease. The skin is dry and itchy, and it involves mostly the hands, arms, and feet. The skin appears thickened with increased skin markings.

Challenge: What's your diagnosis?

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Curtains

This slit-lamp photograph is from a 60 year old gentleman with hypertension, hyperlipidemia, diabetes, myopia, and BPH. He presented acutely with a cobweb appearing in his vision followed by a large black housefly moving in and out of his central vision. He also had flashes of light.

Challenge: What's your diagnosis?

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The Loop

A 32 year old patient presents with a chief complaint of episodes of sudden onset palpitations and "weird feelings in the chest." This is accompanied by dizziness. When he has these episodes, his heart rate is 120-220. An EKG is shown below.

Breaking this arrhythmia can easily be done with adenosine, vagal maneuvers, calcium channel blockers, and beta blockers.

Challenge: What's your diagnosis?

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Palliation

You are a pain physician that performs a neurolytic block for a patient with metastatic pancreatic cancer and severe abdominal pain. He gets hypotensive which resolves with a fluid bolus. He also develops transient diarrhea lasting 48 hours. His pain improves, however, as he is transitioned to palliative care.

Challenge: What procedure did you perform?

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Emergency Options

A 30 year old woman with obesity, epilepsy, and HIV presents to your family planning clinic for emergency contraception. She had unprotected sex 24 hours ago and is worried about pregnancy. She normally does not use any type of contraception, and in fact, has presented for this same concern multiple times in the past year. Her HIV and seizures are well controlled on multiple medications. You counsel her about the risks of unprotected sex, especially in light of being HIV+.

Challenge: What type of emergency contraception is most appropriate here?

See the Stars

A 1 year old boy is brought in by his mother because he suddenly developed intermittent episodes of inconsolable crying. He draws his legs up towards his abdomen during these episodes which happen at 15-20 minute intervals. He initially had non-bilious emesis, but over the last hour, this has become bilious. Between episodes, the child behaves relatively normal.

He had an uneventful birth at full term. He has received all his vaccinations. You feel a sausage-shaped mass on the right side of abdomen.

Challenge: What's the diagnosis?

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Arrow Sign

This is a high resolution CT scan of a healthy 25 year old volunteer.

Challenge: What do the arrows refer to?

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Oops!

You are called to a stroke code. A 50 year old man who was admitted to the hospital with a complicated UTI developed the neuro finding above. He has a past medical history of hypertension, arthritis, and BPH. He has no known neurologic history. He was admitted to the hospital with dysuria and found to have a resistant strain of Pseudomonas. He was started on ciprofloxacin and gentamicin. He normally takes metoprolol, but ran out a couple months ago and was restarted on this hospitalization. This morning, his magnesium was slightly low and was replaced. The rest of his labs are fine. This neurologic finding resolves later this afternoon.

Challenge: What's your diagnosis?

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Stop Bang

A morbidly obese 35 year old gentleman who is 5'5" and 260lbs with a history of obstructive sleep apnea, hypertension, and insulin resistance undergoes pre-operative evaluation for a uvulopalatopharyngoplasty. He has excessive daytime sleepiness, loud snoring, witnessed apnea during sleep followed by a loud snort, fatigue, hypersomnolence, impaired concentration and memory, and a thick neck.

However, you also notice an elevated JVP, hepatomegaly, and some pedal edema. He has dyspnea on exertion and needs to rest after half a flight of stairs. An arterial blood gas shows a PaO2 on room air of 70, a PaCO2 of 48, a bicarbonate of 28, and a Hct of 55. Thyroid studies and electrolytes are normal. Pulmonary function tests show a low FVC, a low FEV1, a low ERV, but a normal FEV1/FVC ratio. EKG suggests right atrial and right ventricular hypertrophy. CXR is normal.

Challenge: Is there something else going on here?

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Runaway

A man in his 30s is dropped off unconscious with multiple gunshot wounds. He is taken to the operating room where he has an exploratory laparotomy, total splenectomy, bowel resection, diaphragmatic repair, and bladder repair. Post-operatively, he leaves against medical advice and is lost to follow-up. He never gets any vaccinations.

Years later, he signs up for a research study for some money. A thoracic CT scan is performed which shows some lung nodules. He is a lifetime nonsmoker.

He decides to go to a physician and gets a heat-damaged RBC scintogram, shown below.

The rest of his review of systems is negative. Other than the gunshot wounds, he's never been sick a day in his life.

Challenge: What's going on?

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