Back ground
Linda G. is a 68-year-old university mathematics professor. She is married with 2 grown children and 4 grandchildren.
Linda was diagnosed with type 2 diabetes mellitus (DM) at the age of 44.
Her blood glucose is usually well controlled by oral antidiabetic agents and diet. At this visit, her blood glucose is normal and her logs indicate good glycemic control throughout the day and pre-and postmeal.
She was diagnosed with hypertension at the age of 55, for which she takes amlodipine besylate 5 mg once daily.
Patient's height: 5'8"; weight: 165 lb.
Blood pressure: 130/91 mm Hg.
Lungs: clear.
Blood glucose: 109 mg/dL.
About a year ago, Linda began to feel numbness in her feet, which gradually worsened, becoming uncomfortable and ascending to involve the distal leg; the discomfort gradually transitioned to pain.
She had been relatively active, walking about a mile to work every day and biking frequently during warm weather. She has recently begun using a cane to help her walk.
Over the last 2 weeks, the pain has gotten progressively worse; it is now intense and burning, and is accompanied by tingling and prickling sensations. Constant for most of the day, the pain is more intense at night and disturbs her sleep.
Her pain has caused her to miss work, and she is wondering if she should take a leave of absence.
She is also worried about weight gain because she is not as active as she used to be.
Linda also states that her discomfort has affected her enjoyment of family and social activities. She no longer participates in university social functions or activities with her family. She has canceled her vacation plans for next month.
On preliminary physical examination, Linda does not appear to have any pustules or rash, nor does she report any outbreaks in recent months.
Examination of her feet reveals a symmetrical pattern of foot pain that is not increased by stimulus.
The most probable cause of pain is Diabetic peripheral neuropathy.
Case27
Case 26
Background
A 64-year-old white male presented with 2 months of soreness of the muscles across his shoulders, lower back, and hips. The patient was also experiencing generalized fatigue and "heaviness" of the forearms after working. The sensation of heaviness in the forearms would start after he used his hands to do his usual daily activities and resolved after resting his forearms for a few minutes.
The patient did not have any complaints of Raynaud's phenomenon, joint pain, chest pain, abdominal pain, bitemporal headaches, jaw claudication, changes in his vision, or claudication of his lower extremities.
His past medical history was unremarkable. He had discontinued smoking 4 years earlier. There was no history of hyperlipidemia.
On physical examination, the patient was afebrile, but blood pressure could not be obtained in either arm. Upper-extremity pulses were absent bilaterally. No bruits were audible in the carotid or axillary areas and there were no digital ulcers. Cardiac examination was normal with no murmurs audible. Pulses in the lower extremities were normal. Bilaterally, temporal arteries were neither enlarged nor tender. There was no scalp tenderness. The joint examination was normal with no joint tenderness or synovitis. No other abnormalities were noted. A work-up was initiated.
On the basis of the patient's presentation, the differential diagnosis at this point would include which of the following?
The correct answer is 'E' All of the above.
Case25
A Puzzling Facial Rash on a 17-Year-Old Boy
Background
A 17-year-old male high school student presents to the pediatric infectious disease clinic complaining of a 10-day history of a facial rash that "won't get better." The patient had previously visited his primary care provider (PCP), who started the patient on amoxicillin-clavulanic acid 8 days ago. The rash did not improve on the antibiotic, and as a result, it was discontinued and the patient switched to trimethoprim-sulfamethoxazole. No improvement was noted with the second round of antibiotic therapy; the rash continued to spread, and the lesions increased in number. The patient was subsequently advised to follow up with the infectious disease clinic.
At the infectious disease clinic, the patient states that the rash started with several pimples over the forehead and cheek and then continued to spread and involve most of the right side of his face. The lesions are not itchy, but they are painful. The patient has no known drug allergies. His immunizations are up to date. He is very active on the wrestling team and was happily preparing for an upcoming competition. The patient denies having any weight loss, headaches, dizziness, photophobia, fever, or chills. The family history is non-contributory.
On physical examination, the patient is alert and orientated. His oral temperature is 97.0°F (36.1°C). The patient has normal heart sounds, his pulse has a regular rhythm of 97 bpm, and his blood pressure is 125/75 mm Hg. His lungs are clear, and his respiratory rate is 12 breaths/min. The examination of the head, eyes, ears, and nose is remarkable for multiple vesicular lesions measuring about 0.5 cm in diameter .There is bilateral submandibular lymph gland enlargement measuring 1.5 cm by 1 cm. The neck is supple. His abdomen is soft and nontender to deep palpation in the epigastric region, and no organomegaly is noted. A complete blood count (CBC) taken at the PCP's office showed a white blood cell (WBC) count of 7.4 × 103/µL (7.4 × 109/L), with a normal differential; a hemoglobin of 13.6 g/dl (136 g/L); a hematocrit of 38.3% (0.3830); and a platelet count of 298 × 103/µL (298 × 109/L).
What is most likely diagnose?
Correct answer is "d" Herpes gladiatorum.
Case24
Back ground
A 34-year-old white woman was seen in consultation regarding a 1-month history of erythematous papules and bullae on the palms and soles. Associated intense pruritus was noted. Initial treatment with an over-the-counter antifungal cream was unsuccessful. The eruption worsened despite treatment with a first-generation cephalosporin and acyclovir, as provided by her primary care physician. There were no reported exposures to toxins, irritants, or potential allergens. The patient was on no other medications, vitamins, or supplements.
On examination, the patient demonstrated tense vesicular lesions on the lateral aspects of the digits of the hands and feet and also on the palmoplantar surfaces (Figure 1). These vesicles terminated abruptly at the wrists and ankles (Figure 2). There was little involvement of the dorsal surfaces. No targetoid lesions were noted. The conjunctiva and oral and genital mucosa were within normal limits. No other cutaneous abnormalities were noted on examination.
What is most likely diagnose?
Answer is "b" Dyshidrotic dermatitis/pompholyx.
Case23
Background
A 72-year-old handicrafts teacher. Recently widowed, Mother of 2 children and grandmother of 4.
She has been diagnosed with a number of chronic health problems over the last several years and is currently receiving treatment for hypertension, osteoarthritis, and chronic obstructive pulmonary disease (COPD).
Despite her doctor's advice, she has found it difficult to lose weight and quit smoking.
Today, her medical status is:
Height: 5'5"; weight:184 lbs; BMI: 30.6 kg/m2
BP: 141/89 mm Hg
Lungs: clear to percussion, but mild wheezing bilaterally
For hypertension: lisinopril 10 mg/hydrochlorothiazide 12.5 mg daily.
For osteoarthritis of the knee: naproxen sodium 375 mg twice daily.
For COPD: fluticasone propionate 100 mcg/albuterol 50 mcg inhalation powder once daily.
Presenting symptoms:
Severe, persistent throbbing pain in the right chest wall, extending from the back to the nipple line.
Pain began with an attack of herpes zoster (HZ) 2 years ago; pain continued through course of acyclovir therapy and persisted after healing of the rash.
Examination reveals an area that is extremely sensitive to light touch within and outside the affected dermatome.
There is some scarring at the site.
she describes her pain as continuous–"like a deep burn" with episodes of sensations that feel like an electric shock
- Which of the following are the most reliable types of information to
diagnose the cause of her pain?
The correct answer is 'd' comprehensive and focused patient history and imaging studies.
Case22
A 36-Year-Old Woman Presents for an ECG Prior to an Elective Cholecystectomy,She received a screening electrocardiogram (ECG) prior to elective cholecystectomy.
History
Past Medical History: Gallstones
Family History: Diabetes
Physical Findings
Age: 36
Gender: Female
Blood Pressure: 114/72 mm Hg
Pulse: 80 bpm
Respiration: 16
General Appearance: Well appearing
The correct Answer is Fusion Beat and A-V dissociation
Case20
Background
A 70-year-old female presented with a three month history of progressive exertional angina and left upper extremity claudication, despite maximum medical treatment.
She also reported left upper extremity pain, which was associated with dizziness and exacerbation of angina. She had no syncope.
Onset: Three-months.
Duration: Each episode lasts two to five minutes.
Past Medical History
Atherosclerotic heart disease with coronary artery bypass graft surgery two years prior.
Diabetes mellitus.
Hypertension.
Mild mitral valve regurgitation.
Family History: Sister with acute myocardial infarction at the age of 50.
Social/Occupational History: Nonsmoker, nondrinker.
Physical Findings
Weight: 128 lbs
Pulse: 70 Regular.
Blood Pressure: Right arm: 140/70 mm Hg; Left arm: 100/62 mm Hg
Head and NEck examination shows Bilateral carotid bruits, left louder than right.Chest and Lungs are Clear to auscultation.Cardiac Exam rvealed Soft systolic murmur over the apex, otherwise normal.Abdomen is Noncontributory. Weak and delayed pulse in the left radial, brachial, and axillary arteries.Neurologic examination is Within normal limits.
Which is most likely to be responsible for the weak pulse in the left upper extremity in this patient?
Click here for diagnose
If carotid and vertebral artery Doppler was performed in this patient, what is the most likely finding?
Correct Answer:Reversal of Blood flow in the left Vertebral artery
case19
Background
A 57-year-old woman presents to her primary care physician with slowly progressive dyspnea, occasional productive cough, poor appetite, and weight loss of 18 pounds.
Her medical history is significant for chronic airflow limitation and hypothyroidism. Apart from decreased breath sounds over the right apex, the findings of her clinical examination are inconclusive.
Lung function is impaired, exhibiting a markedly reduced FEV1, FEV1/FVC ratio, and DLCO with moderately reduced FVC. Routine laboratory results show an elevated ESR of 73 mm/HR (0-23), slight lymphopenia, and slight thrombocytosis. The patient is referred for cross-sectional imaging studies to further evaluate her condition.
Initial contrast-enhanced computed tomographic (CT) studies (not shown) demonstrated marked right apical pleural based thickening without definite mass lesions or mediastinal or axillary lymphadenopathy. A CT-guided fine-needle aspiration biopsy of the right lung apex showed no evidence of malignancy or infection.
Four months later, a repeat contrast-enhanced chest CT study (not shown) demonstrated extensive bi-apical pleural thickening and extensive fibrotic change with multiple thick-walled cavities in both upper lobes with mild mediastinal and left axillary lymphadenopathy. One week later, the patient was referred for dual-modality positron emission tomography/ CT (PET-CT) with 2-deoxy-2[F-18]fluoro-D-glucose (FDG) to acquire additional information regarding her condition.
What is Diagnosis?
Case18
Background
An 8-year-old white girl presented to the emergency department (ED) with a finger injury. Eleven days prior to this, she fell while playing at school and sustained an injury to her right fourth and fifth digits. Nine days prior to the ED visit, she also sustained a burn to her right second digit after touching a curling iron. Local wound care had been performed at home by her mother, and had included daily soaking and wrapping with gauze.
Two days prior to the visit, the girl's fourth finger reportedly developed erythema and began to drain clear fluid from the fingertip. Additionally, the mother noticed "something white" protruded from the end of the fourth fingertip, which "looked like a bone." This fragment was brought with the child to the hospital. An x-ray of the right hand showed a missing distal fourth phalanx.
The patient was admitted to the hospital. Following admission, the patient and her mother denied that she had experienced fever, chills, nausea, bleeding or pain of the affected areas. Her mother stated that her daughter was a "slow healer." In fact, she had a wound on the bottom of her left great toe for 1 year, after stepping on an oyster shell. In spite of having a skin graft to this wound, it still had not healed completely.
Physical Examination
Vital signs: oral temperature 97.9° F, pulse 68, respiratory rate 18/min, blood pressure 114/66 mm Hg.
The child was a thin female who appeared in no acute distress. There were no obvious signs of trauma. Pertinent findings included an old scab on the right second fingertip, edema and slight erythema of the right fourth distal phalanx with a 25-mm opening at the center of the fingertip, and a partially missing right fifth fingernail with erythema surrounding the nailbed. The left great toe had a 0.5-cm defect on the dorsum; the area had a purple discoloration due to the use of gentian violet by her mother. Mild clubbing of all digits was also present.
On neurologic examination, the patient was alert and oriented to person, place, and self and answered questions appropriately. All cranial nerves were intact, with no speech deficits. In all extremities, 5/5 motor strength was observed. There was decreased fine sensation and delayed response to vibratory stimulation on all extremities. The deep tendon reflexes were decreased throughout.
Laboratory Analysis
X-ray of the right hand revealed a partially missing right fifth fingernail, and a missing fourth distal phalanx. An x-ray and MRI of the left foot were suggestive of chronic osteomyelitis of great toe with a pathologic fracture.
On admission, blood cultures were drawn and a culture from the great toe wound was obtained. Intravenous (IV) cefazoline was started empirically. Consultations from Neurology and Orthopaedics were obtained. A neurologic workup was performed to investigate possible causes of the peripheral neuropathy. The results of a hemoglobin A1c; heavy metal screen; levels of vitamins B12, B6, and E and creatinine phosphokinase; serum protein electrophoresis; serum immunoelectrophoresis; and serum cryoglobulins were all within normal limits.
The culture of the great toe wound subsequently grew Enterococcus spp. An MRI of the spine was also within normal limits.
Nerve Conduction Studies
Motor conduction study of the peroneal nerve and left median nerve bilaterally revealed mildly slowed motor conduction velocity and significantly small compound muscle action potential amplitude. Right ulnar and tibial nerve motor conduction study showed low normal motor conduction velocity and normal compound muscle action potential amplitude.
Needle examination of the right lower extremity revealed signs of subtle denervation and reduced interference pattern in the feet muscles, consistent with neuropathy. The findings from this study were indicative of motor-sensory neuropathy, predominantly sensory, most likely hereditary.
What is Diagnosis?
Diagnose:HMSN-type II neuropathy (Charcot-Marie-Tooth [CMT] disease)
case17
Background
A 7-month-old black female with a history significant for failure to thrive was transported to our facility from an outlying hospital with acute respiratory failure. Her parents stated that since discharge from a previous hospitalization at 4 months of age, the infant has had multiple episodes of coughing and wheezing. On the day prior to admission, her respiratory symptoms worsened and she was started on bronchodilators. On the day of admission, she had deteriorated further, presenting with severe sternal retractions, wheezing, and decreased oral intake and activity. On arrival to the emergency department, she was assessed as being in respiratory failure with altered mental status, and was immediately intubated.
The patient was born at 37 weeks gestational age to a group B Streptococcus-positive mother. The birth weight was 6 pounds, 11 ounces (50th percentile). The infant was hospitalized at 4 months of age for respiratory syncytial virus (RSV) pneumonia and respiratory failure. This hospital course was complicated by Staphylococcus aureus sepsis and a Candida urinary tract infection. The baby lives with her parents and her 4-year-old twin male siblings. The parents stated that although the baby previously had been eating well, she had continued to lose weight despite the use of 27 calories per ounce formula. They denied the occurrence of any episodes of vomiting or diarrhea. According to the parents, neither of the patient's siblings has had any chronic medical problems, previous hospitalizations, or delay in growth. The family denied a history of recent travel out of the country or exposure to sick contacts.
Rectal temperature 98° F, pulse 180 beats/min, respiratory rate 36/min on the ventilator, blood pressure 108/54 mm Hg, SpO2 97% on 50% oxygen. Weight 4.68 kg
What is diagnosis?
Case16
A Traveler’s Fever
Background
A 17-year-old man presents to the emergency department (ED) complaining of a headache that has lasted for the past 2 days. The patient states that he returned to the United States 2 days ago after spending 3 weeks in Nigeria. According to the patient, he felt well when he initially arrived in the United States, but he developed a severe headache soon after. The headache is constant and throbbing, is lasting throughout the day, and is relieved with ibuprofen. He complains of subjective fevers and intermittent sweats, especially at night, but he has not taken his temperature.
Today, while preparing to board a plane, he developed a worsening headache, bilious emesis, palpitations, and sweats. He decided to delay his trip and is now presenting to the local ED for further evaluation. The patient denies having any trauma, seizures, abdominal pain, stiff neck, or photophobia. He has no significant past medical history, and his only medication use is the ibuprofen that he has taken over the past 2 days.
On physical examination, his temperature is 103.0° F (39.4° C), his pulse is 83 bpm, his blood pressure is 120/70 mm Hg, his respiratory rate is 16 breaths/min, and his oxygen saturation is 96% while breathing room air. The patient is generally well-appearing, alert, and oriented. The examination of the head, eyes, and pupils is unremarkable. The neck is supple, without any lymphadenopathy. On auscultation, the lungs are clear; additionally, the patient's heart has a regular rate and rhythm, without any murmurs.
The examination of the abdomen reveals normal bowel sounds, with mild tenderness to palpation in the right and left upper quadrants. The spleen is noted to be 3 cm below the costal margin. The neurologic examination is unremarkable.
The patient is treated with intravenous fluids. An electrocardiogram (ECG) shows a normal sinus rhythm, with a QTc of 390 msec. Serum laboratory tests are done, and they are significant for the following values: creatinine, 1.2 mg/dL (106.08 µmol/L); magnesium, 1.2 mg/dL (0.49 mmol/L); alanine aminotransferase (ALT), 110 U/L (normal range 0-35 U/L); aspartate aminotransferase (AST), 159 U/L (normal range 0-35 U/L); total bilirubin, 2.7 mg/dL (46.17 μmol/L) (normal range <1.20>
What is the diagnosis?
Case15
Background
A 35-year-old woman was referred to Johns Hopkins Hospital, Baltimore, Maryland, for a brain biopsy. The patient initially presented to a local community hospital following 5 days of blurred vision associated with headache and 2 days of left face, arm, and leg numbness. These symptoms had come on gradually, were becoming progressively worse, and were accompanied with generalized fatigue and anxiety. She also complained of a dry cough and dyspnea on exertion. She denied any fever, chills, night sweats, or weight loss. She reported no contacts with other sick individuals and no recent travel outside her hometown. She did not own any pets.
The patient had diabetes mellitus type 2. She had undergone a hysterectomy a few years earlier for cervical cancer. She also had been diagnosed with pulmonary alveolar proteinosis (PAP).She lived with her husband; they had no children. She reported a 20-year, 2-packs-per-day smoking history, but had recently cut down to 1 pack per day. She denied any alcohol or illicit drug use.Her family members were known to have coronary artery disease, hypertension, and diabetes.
The patient's initial physical exam from the local hospital was not available. She reported that she did not have a fever, and although her left side felt numb and heavy, she was able to walk.
Initial Laboratory Studies
White blood cell count: 9.7 x 103 cells/mm3.
Hematocrit: 43%.
Platelets: 256,000 cells/mL.
Na: 137 mEq/L.
K: 3.9 mEq/L.
BUN: 16 mg/dL.
Creatinine: .6 mg/dL.
Albumin: 3.6 g/dL.
Protein: 7 g/dL.
Alkaline phosphatase: 67 IU/L.
AST: 12 IU/L.
ALT: 36 IU/L.
The patient underwent head computed tomography (CT) and magnetic resonance imaging (MRI) of the brain. These showed multiple, bilateral lesions with surrounding edema on fluid-attenuated inversion recovery (FLAIR) images (Figure 1), which appeared ring-enhancing on postgadolinium images.
Which of the following would be the least likely cause of ring-enhancing brain lesions in an immunocompetent patient?
Case 14
Long History of Irritable bowl
Background
A 43-year-old man with a history of hypothyroidism and a long, subjective history of "irritable bowel."
The patient presented with a 9-month history of progressively worsening pruritic papules involving the elbows, scalp, lower back, and buttocks. He was initially treated for scabies with permethrin 5% cream but experienced no improvement in his symptoms. Over the subsequent 8 months, he was treated with triamcinolone 0.1% ointment, pimecrolimus cream, econazole cream, oral prednisone, and antihistamines without improvement. He described his pruritus as so severe that it impaired his ability to concentrate at work and sleep at night. The only other medication he takes regularly is levothyroxine. Biopsies were performed.
On examination, the patient was pleasant, alert, and oriented, but it was noted that he scratched repeatedly. He had excoriated papules and a few intact vesicles distributed on the bilateral elbows, lower back and buttocks, and scalp. A skin scraping for scabies was negative.
Routine staining with hematoxylin and eosin demonstrated neutrophilic infiltration of the dermal papillae with vesicle formation.The epidermis was unremarkable and there was no evidence of vasculitis. A biopsy submitted for direct immunofluorescence demonstrated 3+ granular staining of dermal papillary tips with immunoglobulin A (IgA) . There was 1+ scattered staining of dermal blood vessels with C3. IgG and IgM staining was negative.
What is your diagnosis?
Case13
A Middle-Aged Man with Vesiculobullous Lesions on His Feet and Hands
Background
A 57-year-old man with a history of diabetes mellitus and hypertension presents to the emergency department (ED) with a 2-week history of vesiculobullous lesions on his feet and hands.
The lesions first appeared on both of his feet and have been increasing in size and number; over the last several days, they have begun to develop on both of his palms and on the sides of the fingers. The patient was seen at a different clinic approximately 1 week ago and was given an ointment to treat the lesions; this has not resulted in any improvement. The lesions are extremely pruritic. The patient has not had any recent travel history, and he lives alone, without any pets, in a regularly cleaned apartment. He has had no discernible new exposures and has not experienced any fevers or constitutional symptoms. The patient is on insulin, labetalol, and a combination pill of lisinopril/hydrochlorothiazide plus omeprazole; he has been on these medications for a long time and has had no prior complications. The patient has no known allergies.
On physical examination, the patient is well-appearing at rest, without any signs of undue anxiety or discomfort. His vital signs show a temperature of 98.7ºF (37.1ºC), blood pressure of 130/85 mm Hg, heart rate of 70 bpm, respiratory rate of 18 breaths/min, and oxygen saturation of 98% while breathing room air. Fluid-filled vesicles ranging in size from 1 mm to 3 cm are present on the instep and plantar aspects of his feet (see Figures 1 & 2). The vesicles are present on the palms of his hands and the sides of the fingers as well. The lesions are all skin-colored, without any surrounding erythema. No other lesions are found anywhere else on the patient's body. The lesions are nontender to palpation; additionally, his legs exhibit nonpitting edema up to the knees and reduced sensation to light touch, both long-standing conditions. The oropharynx is clear of any lesions, and the rest of the physical examination is unremarkable.
What is the skin condition being described?
Hint: Pay particular attention to the anatomic clustering of the lesions
Case12
Chest Pain and Shortness of Breath in a 59-Year-Old Man
BACKGROUND
A 59-year-old man presents to the emergency department (ED) with a 6-month history of progressive shortness of breath as well as new onset of mild chest pain. He has no history of fever, chills, coughing, hemoptysis, weight loss, or smoking. He is otherwise healthy and does not take any medications on a regular basis.
On physical examination, the patient is afebrile, with normal vital signs, including an oxygen saturation rate of 99% while breathing room air. He does not appear to be in acute distress. The cardiovascular examination reveals conjunctival pallor. No evidence of muscle weakness or neurologic deficit is noted. Routine laboratory studies reveal a white blood cell (WBC) count of 7200/µL, a hemoglobin level of 10.1 g/dL (101 g/L), a hematocrit of 36% (0.36), and a platelet count of 120,000/µL (120 × 109/L).
Routine posteroanterior (PA) and lateral chest radiographs are obtained, and a computed tomography (CT) scan is ordered.
What is the diagnosis?
HINT
Note the large, lobulated, noncalcified soft-tissue mass in the anterior mediastinum in this older patient who presents with mild chest pain and dyspnea.
Case11
Pink Red Urine in a Child Who Ingested Prenatal Vitamins
Background
A 2-year-old boy is brought to the emergency department (ED) several hours after ingesting an unknown number of his mother's prenatal iron tablets.
His parents report that the child has been vomiting bright-red blood and has had 1 episode of bloody diarrhea. He has no history of medical problems and does not currently take any medications on a regular basis.
On physical examination, the child appears lethargic and irritable. His temperature is 99.0ºF (37.2ºC), with a heart rate of 150 bpm, a respiratory rate of 24 breaths/min, and a blood pressure of 88/55 mm Hg. His cardiorespiratory findings are otherwise unremarkable. On abdominal examination, he has diffuse, mild tenderness to palpation. The child is moving all of his extremities.
Acute iron toxicity is diagnosed, and the patient's hemodynamic status is stabilized with boluses of isotonic intravenous fluid. A plain radiograph of the abdomen does not reveal any retained tablets. Laboratory studies, including a serum iron level measurement, are performed, and the child is admitted to the intensive care unit for further treatment. Upon noting the gastrointestinal symptoms, acidemia, and continued lethargy with confusion, the consulting toxicologist recommends treatment with a specific pharmacologic agent. Shortly after the agent is administered, the child's urine changes from yellow to pink-red (see Figure 1). The laboratory result for the serum iron level that was obtained approximately 4 hours after the iron-tablet ingestion was 1200 µg/dL.
What is the cause of the pink-red urine seen in this iron toxicity case?
Hint: Chelation therapy was administered for the iron toxicity.
Case10
Near-Syncope in a 24-Year-Old Man
Background
A 24-year-old man with no significant past medical history presents to the emergency department (ED) with a complaint of several episodes of a sensation of nearly blacking out. The episodes have occurred about 3-4 times over the 3 days before presentation. The duration of each episode has ranged from a few minutes to over an hour. The patient notes that he has felt his "heart beating really fast," with associated light-headedness. He denies having any chest pain, shortness of breath, or nausea associated with these events. He cannot identify exacerbating or alleviating factors; specifically, he denies exertion as an inciting factor. The remainder of his review of systems is negative except for some mild chronic shortness of breath. The patient takes no medications at home and has no active medical conditions. He smokes 2-4 packs of cigarettes per day and has done so for 5-6 years. He denies any illicit drug use or recent use of over-the-counter medications or herbal remedies. He has no history of any significant cardiac disease or sudden cardiac death in his family.
On physical examination, the patient is afebrile, with a pulse of 65 bpm, a blood pressure of 120/84 mm Hg, and a respiratory rate of 15 breaths/min. His room air saturation reading is 100%. In general, he is well-appearing and in no acute distress. The patient's neck examination shows no jugular venous distention. The heart sounds, including S1and S2, reveal no audible murmurs, rubs, or gallops. The apical impulse is nondisplaced and of normal impact. The lung sounds are diminished throughout, but there are no wheezes, rales, or rhonchi. He has no edema of the lower extremities, and the distal pulses are easily palpable. All other exam findings, including a neurologic examination, are unremarkable.
The patient is placed on a cardiac monitor, and an 18-gauge intravenous (IV) catheter is inserted into the antecubital fossa. Laboratory tests consisting of a complete blood count (CBC) and serum electrolytes are ordered. A portable chest radiograph reveals slight hyperinflation and hyperlucency of the lung fields, with a flattened diaphragm and central pulmonary artery enlargement. An electrocardiogram (ECG) is obtained.
What is the diagnosis?
Hint: Pay close attention to the intervals and the QRS complex morphology.
Case9
Acute Onset of Abdominal Pain in a 76-Year-Old Man
Background
A 76-year-old man presents to the emergency department (ED) complaining of a sudden onset of abdominal pain.
The pain started about 4 hours before presentation to the ED and has been persistent; it is present in the upper abdomen and is centered in the epigastrium. He describes the pain as deep and burning. There is no associated nausea or vomiting. He does not report any changes in his bowel habits and has not experienced any recent fevers. The review of systems is also negative for any recent unintended weight loss or trauma. The patient also reports having had "indigestion" in the past that caused pain similar to what he is currently experiencing, though much less in intensity. His past medical history is significant for coronary artery disease and hypertension. He takes two medications, both for his high blood pressure, but does not drink excessively and does not smoke.
On physical examination, the patient is pale and in obvious severe discomfort. His heart rate is 122 bpm, and his blood pressure is 110/65 mm Hg. He is breathing with rapid shallow breaths at a rate greater than 30 breaths/min. His temperature is normal at 99.2ºF (37.3ºC), and a pulse oximetry reading while the patient is breathing room air shows a saturation rate of 100%. The cardiovascular and respiratory findings are unremarkable. The patient has significant tenderness in the epigastric region, with a rigid abdomen. There is little to no tenderness to palpation in the lower quadrants; a reliable assessment of the upper quadrants is not possible because of the tenderness in the epigastric region. Hyperactive bowel sounds are heard on auscultation. The patient's stool is brown and guaiac positive.
An electrocardiogram is performed and is noted to be unremarkable except for sinus tachycardia. A complete blood count (CBC) and a chemistry panel are sent. The CBC reveals a mild anemia, with a hemoglobin concentration of 127 g/L (12.7 g/dL). On the chemistry panel, there is evidence of a slight azotemia, with a blood urea nitrogen level (BUN) of 17.1 mmol/L (48 mg/dL) and a creatinine value of 106 µmol/L (1.2 mg/dL). The remainder of the laboratory investigations are unremarkable. Plain radiographs of the abdomen are performed.
What is Diagnosis?
Hint: Both the inner and the outer walls of the bowel are visible.
Case8
Red and Swollen Eye in a 61-Year-Old Man
Background
A 61-year-old man presents to the emergency department (ED) complaining of pain in his right eye that has persisted for 5 days, with associated redness and swelling.
The patient had been examined at another ED a few days before this presentation and was diagnosed with herpes zoster, for which he was given a prescription for acyclovir and hydrocodone and discharged home.
Since he started taking acyclovir, the patient has noticed that the pain and swelling in his eye has increased. He also reports binocular diplopia and decreased visual acuity. On the day of presentation, he is nauseous and vomiting, and he cannot open the affected eye.
On physical examination, the patient has normal and stable vital signs. Visual acuity in the unaffected left eye is normal at 20/25. In the right eye, he can only perceive bright light. In addition, the affected eye demonstrates ptosis of the upper eyelid, generalized proptosis, and mild periorbital erythema with associated edema (see Figure 1). Extraocular movements of the affected eye are as shown (see video clip). The right pupil is 8 mm in diameter and nonreactive to direct and indirect light. Intraocular pressure in both eyes, as measured by a handheld tonometer (Tono-Pen), is normal at 12 mm Hg.
What is the diagnosis?
Hint: The patient has diabetes mellitus and has been unable to control his blood glucose levels over the past 2 weeks.
Case7
Fleshy Lesions on a 32-Year-Old Woman
Background
A 32-year-old woman presents to the emergency department (ED) with several flesh-colored papules on her face, trunk, and upper extremities.
She first noticed the lesions at approximately 10 years of age; however, over the past 5 years, the lesions have increased in number and become uncomfortable. She primarily complains of irritation from the lesions along her bra line. She underwent excision of similar skin lesions 5 years ago, but they have since recurred. She denies having any discharge, pain, trauma, contact with individuals with atypical skin lesions or rashes, travel out of the country, unusual exposure to animals, or a history of sexually transmitted diseases.
The patient's medical and surgical history includes environmental allergies, frequent episodes of bronchitis, and the aforementioned excisions. She has no known drug allergies, and she takes cetirizine HCl and fluticasone propionate for seasonal allergies. Her family history is significant for coronary artery disease, hypertension, diabetes mellitus, and glaucoma, but there is no family history of similar lesions. She does not smoke and only drinks alcohol on occasion. The review of her systems is otherwise unremarkable.
The physical examination reveals dozens of 0.5-2.0 cm fleshy nodules spread over her trunk, face, and upper extremities. The nodules are nontender to palpation and nonerythematous, and they produce no discharge, crusting, or scaling. Several tan oval macules measuring 1.5-3 cm in size and patches with well-defined borders are located on her trunk and upper extremities (see Images). Her vital signs are within normal limits, and her other physical findings are unremarkable.
What is the diagnosis?
Hint: Tan macules or patches, known as "café-au-lait spots," are characteristic of this genetic disorder
Case6
Woman With an Acute Onset of Nausea and Vomiting
Background
......................
A 46-year-old woman presents to the emergency department (ED) with a history of worsening, constant right upper quadrant pain that radiates to her back and side. She has had nausea and has vomited twice in the past several hours. She underwent a laparoscopic cholecystectomy 2 weeks ago, without complications, and returned to her normal diet. She has not had any bowel movements or flatulence since the pain began. She denies having any fever, chills, or rigors. Her medical history is significant only for high blood pressure, high cholesterol levels, and gallbladder disease. She takes lisinopril, aspirin, multivitamins, and ginseng. She denies smoking or drinking alcohol.
On physical examination, the patient is awake, alert, and oriented. Her vital signs are within the normal range, with a heart rate of 84 bpm and a blood pressure of 124/76 mm Hg. She appears to be in mild distress. The cardiorespiratory examination yields normal findings, with clear lungs and a regular heart rhythm. Her abdomen is soft, but her bowel sounds are decreased, and she has marked tenderness in the right upper quadrant. The rest of her abdomen is minimally tender, with no evidence of guarding or rebound and no palpable masses. The other physical findings are normal.
The laboratory investigation reveals an elevated WBC count of 14.0 × 109/L (14.0 × 103/µL), with a left shift of 87% neutrophils. Her liver function tests, lipase level, and basic chemistry panel are unremarkable.
Contrast-enhanced computed tomography (CT) scans of the abdomen and pelvis are ordered. Figure 1A shows an anteroposterior (AP) scout image, and Figure 1B shows a selected axial section.
Fig.1
what is the diagnosis?
Hint: This entity is commonly described as various foods, especially "beans".
Case5
An Atypical Cause of Gastrointestinal Bleeding
Background
A 53-year-old man who was diagnosed with multiple myeloma (IgAκ) 18 months ago is admitted to the hospital via the emergency department (ED) with a 1-week history of melena, hematemesis, and lethargy. There is no associated weight loss, abdominal pain, dysphagia, or history of upper gastrointestinal (GI) hemorrhage. The patient has no risk factors for peptic ulcer disease, does not drink alcohol or smoke, and is not regularly taking any medications (including no recent nonsteroidal anti-inflammatory drugs [NSAIDs] or steroid use). He has no allergies of note, and his family history and social history are unremarkable. Other than multiple myeloma, which resulted in spinal cord compression that required radiotherapy (with full resolution of symptoms), the patient has no significant past medical history. He has not needed chemotherapy to date. On direct questioning, he does not describe any symptoms suggestive of active multiple myeloma and organ involvement.
On presentation, the patient appears clinically well, with no evidence of anemia, jaundice, lymphadenopathy, or peripheral signs of GI disease. He is hemodynamically stable, with a pulse of 90 bpm, blood pressure of 150/70 mm Hg (with no postural blood pressure drop), and a urine output of approximately 30 mL/hr. On examination, there is no evidence of active GI bleeding, his abdomen is soft and without any peritonitis or organomegaly, and a rectal examination shows evidence of melena, with no masses and a normal-sized prostate. His respiratory examination is unremarkable, with a clear chest and no evidence of aspiration pneumonia. The cardiac and neurologic examinations reveal nothing of significance.
The initial laboratory examinations show a hemoglobin of 8.5 g/L (0.85 g/dL); a low mean corpuscular volume (79 fL), with an iron deficiency picture; a normal international normalized ratio of 1.0; and mild dehydration, with urea nitrogen 10.1 mmol/L (28.29 mg/dL), creatinine 160 µmol/L (1.81 mg/dL), sodium 136 mmol/L (136 mEq/L), and potassium 3.9 mmol/L (3.9 mEq/L). Liver tests showed a normal screen with alanine aminotransferase 30 U/L, albumin 40g/L (4 g/dL), alkaline phosphatase 50 U/L, and bilirubin 12 µmol/L (0.70 mg/dL). The patient is treated with intravenous fluid and 2 units of blood. He remains hemodynamically stable and is subsequently able to undergo an esophagogastroduodenoscopy .
What is the cause of the abnormalities seen on the endoscopy?
Case4
Small-Bowel Obstruction While on a Cruise
Background
A 57-year-old man with severe abdominal pain is evacuated from a cruise ship and presents to a local emergency department (ED).
The pain, which is most severe in the right lower portion of his abdomen, started soon after he boarded the cruise ship 2 days before presentation. Since onset, the pain has worsened, and the patient has noticed his abdomen becoming progressively "bloated." The pain is associated with nausea and vomiting, and the patient has not been able to have a bowel movement.
On physical examination, the patient is alert and oriented. His temperature is 98.8°F (37.1°C), his pulse is 65 bpm, his respiratory rate is 18 breaths/min, and his blood pressure is 104/67 mm Hg. The abdominal examination reveals localized tenderness to palpation in the right lower quadrant (RLQ) with a palpable mass. He has generalized abdominal distention but no guarding, rebound, or percussion tenderness. His rectal examination reveals brown stool that is guaiac-positive. The findings from the respiratory and neurologic portions of the physical examination are unremarkable.
Laboratory investigations are ordered and reveal a hemoglobin value of 9.4 g/dL (94 g/l), with a corresponding hematocrit of 30.8% (0.308). His white blood cell (WBC) count is 6.2 × 103/μL (6.2 × 109/L), and his lactate dehydrogenase (LDH) level is elevated at 285 U/L.
What is the likely etiology leading to this small bowel obstruction?
Hint: Note the patient's strong family history of cancer.
Case 3
A 55-Year-Old Woman with Shortness of Breath and a Rapid Heart Rate
BACKGROUND
A 55-year-old woman presents to the emergency department (ED) with severe, progressive shortness of breath, with associated chest pressure and wheezing. She has labored respirations and is unable to speak in full sentences; she also has a 40-pack-year history of tobacco use, as well as a history of alcoholism. She used her albuterol inhaler before contacting emergency medical services (EMS), but there was no relief of her symptoms. An electrocardiogram (ECG) is performed, and it shows tachycardia at 152 bpm, with a left bundle branch block.
What is the rhythm demonstrated on the ECG?
(HINT :The rhythm can sometimes be difficult to differentiate from a supraventricular tachycardia. )
case 2
The Unrestrained Driver
BACKGROUND
A 26-year-old man is involved in a high-speed motor vehicle collision. The patient’s oropharynx is clear, his airway is patent, and his trachea appears to be shifted to the right of midline. The patient’s breath sounds are decreased and percussion of the left chest demonstrates hyperresonance. Standard trauma x-rays, including an anteroposterior (AP) chest and pelvis scan, and an emergent procedure are performed.
What is the underlying pathology, and what procedure was performed?
Hint: The cause of this patient's hypotension and hypoxia is a clinical diagnosis, and although a portable chest radiograph was performed in this case, this condition should not typically require imaging
Case 1
Rapid Heart Rate and Shortness of Breath in a 40-Year-Old Man
BACKGROUND
A 40-year-old man arrives at the ED with sudden-onset palpitations and shortness of breath. Paramedics had observed a rapid heart rate on the cardiac monitor and associated rhythm strips; they administered adenosine 0.6 mg en route to the hospital. The patient had a momentary period of asystole, but his rapid heart rate returned. He reports increased stress at work and is drinking as many as 4 cups of coffee a day; additionally, he smokes 3 packs of cigarettes per week. An ECG is obtained.
What is Diagnose?
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