A 62-year-old female with a history of sarcoidosis and hypertension presents to the ED for 4 days of fever, vomiting, malaise and generalized abdominal pain that is worst in the right upper quadrant.  Her vitals are normal except for a temperature of 102.1 F.  Her exam is otherwise normal except for generalized abdominal tenderness with guarding in the right upper quadrant, an enlarged spleen and a few petechiae on both shins.

An abdominal ultrasound shows a dilated gallbladder with a thickened wall and pericholecystic fluid, but no stones or sludge.  The spleen is also noted to be enlarged.  Her lab tests are notable for a sodium of 127, an AST of 441, an ALT of 288 and a platelet count of 14,000.  A blood smear is done due to the low platelets.

What diagnostic finding is shown in the smear below? What is the diagnosis? What is the treatment?

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A 68 year old male presents with urinary retention and shortness of breath. He states that he has a prostate problem and that “his penis hole is in the wrong place”, but is not on an alpha blocker and has never been offered surgery. Instead he uses a catheter.  He next takes out an old ziplock bag and produces a nasty-looking straight cath. Answers to various other questions confirms that he has had quite fragmented health care. No one ever even suggested that he apply for Medicare!

On exam he is in mild respiratory distress, but vital signs and pulse-ox are normal. He has both rales and peripheral edema.  He also has hypospadia, but his bladder doesn’t really feel that enlarged.

The nurse is unable to pass a Foley or a Coude and asks you if you want to try a straight cath. You answer that you want to do a quick bedside ultrasound of his bladder first. By then his labs have returned. You are not surprised by his raging UTI, elevated creatinine or elevated BNP, though the troponin of 0.2 does raise an eyebrow.

Below is the ultrasound image of the bladder that you obtain.

What does this ultrasound show?

Bonus Question: What EKG finding is pathognomonic for hypospadia

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A 50-year old man presents to the ED with nausea, vomiting and generalized weakness. He has no known past medical history, but has not seen a doctor in “years”. He denies chest pain, abdominal pain, change in bowel movements, headache and fever. He has no other complaints.

On exam his vital signs are normal, but he just doesn’t look right. His tongue is a bit dry. There is no JVD. Lung have a few bibasilar rales, but are mostly clear. Heart sounds are normal. The abdomen is non-tender without mass. He has trace bilateral edema.

Below is his EKG. What does it show? What do the second EKG show?

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A 33-year-old G1P1 Caucasian female presents with intermittent episodes of weakness, abdominal discomfort and nausea lasting days at a time over the past 3 months. Except for treated hypothyroidism she has no other medical problems.

On exam she is alert, thin, well-tanned, in no acute distress and non-toxic. Vitals are normal except for a BP of 84/56. Her exam is otherwise unremarkable. She looks well hydrated. Her abdomen is benign.  Pelvic exam is refused because “the pain isn’t down there.”

Look at the picture below and use the few clues from the case narrative. What does she have?

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A 32-year-old male presents to the ED with a wrist injury after falling from his skateboard. He has no other injuries or complaints. His x-ray is shown below. How may injuries can you find?

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