Case Studies Flashcards
(152 cards)
1
Q
A 42-year-old man undergoes trans-sphenoidal surgery for a large, non-functioning pituitary macro-adenoma. Preoperatively, dynamic pituitary hormone tests were normal, as was his fluid intake and output. Two days following surgery he developed acute polyuria, extreme thirst, and polydipsia. His urine output over the next 24 hours was 6 litres, with frequent nocturia
A
DIABETES INSIPIDUS
2
Q
A 48-year-old man has a 4-month history of increasing fatigue and anorexia. He has lost 5.5 kg and noticed increased skin pigmentation. His mother has Hashimoto’s thyroiditis and one of his sisters has type 1 diabetes. His blood pressure is 110/85 mmHg (supine) and 92/60 mmHg (sitting). His face shows signs of wasting and his skin has diffuse hyperpigmentation, which is more pronounced in the oral mucosa, palmar creases, and knuckles
A
ADDISON’S DISEASE
3
Q
A 75-year-old man presents to his GP abdominal pain and constipation. He has a past medical history of kidney stones and fracture. He has also been feeling down recently. On ECG he has a short QT interval
A
HYPERCALCAEMIA
4
Q
A 68-year-old woman presents to her GP with spasms of the hands and feet, cramps and numbness. On examination, when tapping over her facial nerve, her face twitches. When the doctor tried to take her blood pressure, she experiences a carpopedal spasm. On ECG she has a prolonged QT interval.
A
HYPOCALCAEMIA
5
Q
A 12-year-old white girl is brought to the emergency department by her parents due to 12 hours of rapidly worsening nausea, vomiting, abdominal pain, and lethargy. Over the last week she has felt excessively thirsty and has been urinating a lot. Physical examination reveals a lean, dehydrated girl with deep rapid respirations, tachycardia, and no response to verbal commands
A
T1DM
6
Q
A 45-year-old man with a history of type 2 diabetes is admitted directly from clinic for a serum glucose of 53.8 mmol/L (970 mg/dL). He was started recently on basal bolus insulin therapy after several years of treatment with oral antiglycaemic agents. However, he reports not having followed his insulin prescription because he struggles to inject himself. For the past 2 weeks he has had polyuria and polydipsia, and has lost 5 kg in weight. He has also noted a progressively worsening cough for approximately 3 weeks that is productive of greenish-brown sputum.
A
HYPEROSMOLAR HYPERGLYCAEMIC STATE
7
Q
A 38-year-old woman, who in the past had tried to lose weight without success, is happy to see that in the last 2 months she has lost about 11 kg (25 pounds). She also has difficulty sleeping at night. Her husband complains that she is keeping the house very cool. She recently consulted her ophthalmologist because of redness and watering of the eyes. Eye drops were not helpful. She consults her doctor for fatigue and anxiety, palpitations, and easy fatigability. On physical examination, her pulse rate is 100 bpm and her thyroid is slightly enlarged. Conjunctivae are red and she has a stare.
A
GRAVE’S
8
Q
A 45-year-old white woman presents with symptoms of fatigue, depression, and mild weight gain. Physical examination demonstrates heart rate of 58 beats per minute, coarse dry skin, and bi-lateral eyelid oedema
A
HYPOTHYROIDISM
9
Q
A 50-year-old woman with a past medical history of renal disease notices she is getting fatigue and chest pain. After examination she also presents with hyporeflexia, flaccid paralysis and cardiac arrhythmia. On ECG they find tall, tented T waves with absent P waves
A
HYPERKALAEMIA
10
Q
A 45-year-old woman presents with sweating, nausea, and headache. She does not have any significant prior medical illnesses. The symptoms typically occur when she has skipped a meal or not had anything to eat for several hours, although they have rarely occurred within a couple hours of a meal as well. She does not snack between meals and reports that her weight has been stable. She has never lost consciousness, but has become very confused and distractible. If she does not eat soon after, she begins to feel nauseated and sweaty. She has found that the symptoms quickly resolve after eating
A
HYPOGLYCAEMIA
11
Q
A 76-year-old white man presents to the emergency department with night sweats, headache and oedema. He recently suffered a pulmonary infection. On examination, his jugular venous pressure is dramatically increased. The patient’s plasma and urine osmolality are reduced and he has a high urinary sodium.
A
SIADH
12
Q
An overweight 55-year-old woman presents for preventative care. She notes that her mother died of diabetes, but reports no polyuria, polydipsia, or weight loss. BP is 144/92 mmHg, fasting blood sugar 8.2 mmol/L (148 mg/dL), HbA1c 65 mmol/mol (8.1%), LDL-cholesterol 5.18 mmol/L (200 mg/dL), HDL-cholesterol 0.8 mmol/L (30 mg/dL), and triglycerides 6.53 mmol/L (252 mg/dL)
A
T2DM
13
Q
A 50-year-old man presents with weakness, constipation and cramping. He was recently started on hydrochlorothiazide (a thiazide diuretic) and on ECG they find flat T waves, ST depression and U waves
A
HYPOKALAEMIA
14
Q
A 20-year-old man is brought to the accident and emergency department with abdominal pain, nausea, and vomiting with increasing polyuria, polydipsia, and drowsiness since the previous day. He was diagnosed with type 1 diabetes 2 years previously. He mentions that he ran out of insulin 2 days ago. Physical examination reveals Kussmaul’s breathing (deep and rapid respiration due to ketoacidosis) with acetone odour and mild generalised abdominal tenderness without guarding and rebound tenderness
A
DIABETIC KETOACIDOSIS
15
Q
A 28-year-old woman presents with a 2-year history of hypertension, associated with nocturia (4-5 times per night), polyuria, palpitations, limb paraesthesias, lethargy, and generalised muscle weakness. There is no other past medical history. Physical examination is unremarkable apart from a blood pressure (BP) of 160/100 mmHg, global hyporeflexia, and weak muscles
A
CONN’S SYNDROME
16
Q
A 47-year-old man presents with arthritic pain of knees and hips, soft-tissue swelling, and excessive sweating. He also noticed progressive enlargement of the hands and feet. He has been taking antihypertensive medicine for the past 3 years. On physical examination, he has coarse facial features with prognathism and prominent supra-orbital ridges. The tongue is enlarged and the fingers are thickened. His wife complains that he frequently snores.
A
ACROMEGALY
17
Q
A 34-year-old woman presents with complaints of weight gain and irregular menses for the last several years. She has gained 20 kg over the past 3 years and feels that most of the weight gain is in her abdomen and face. She notes bruising without significant trauma, difficulty rising from a chair, and proximal muscle wasting. She was diagnosed with type 2 diabetes and hypertension 1 year ago.
A
CUSHING’S SYNDROME
18
Q
A 33-year-old woman presents to her doctor complaining of a several-month history of episodic palpitations and diaphoresis. She has been experiencing progressive episodic headaches, which are not relieved by paracetamol. She has a history of kidney stones and hypercalcaemia. Her family history is unremarkable; specifically, there is no history for tumours, endocrinopathies, or hypertension. Physical examination reveals a BP of 220/120 mmHg and hypertensive retinal changes
A
PHAEOCHROMOCYTOMA
19
Q
A 42-year-old man presents with a recent history of abdominal pain, distension, and nausea. Urea breath testing for Helicobacter pylori is positive
A
GASTRITIS
20
Q
A 22-year-old male presents to the emergency department with abdominal pain, anorexia, nausea, and low-grade fever. Pain started in the mid-abdominal region 6 hours ago and is now in the right lower quadrant of the abdomen. The pain was steady in nature and aggravated by coughing
A
ACUTE APPENDICITIS
21
Q
A 77-year-old man presents to his general practitioner with weight loss of 6.8 kg (15 lbs) and a 3-month history of dysphagia and abdominal pain. The only abnormal finding on physical examination is stools positive for occult blood. He is referred for an upper endoscopy, which shows an exophytic, ulcerated mass in the cardia of the stomach.
A
GASTRIC CANCER
22
Q
A 27-year-old man with a 3-month history of rectal bleeding and diarrhoea is referred for evaluation. Laboratory tests show mild anaemia, a slightly elevated sedimentation rate, and the presence of white blood cells in stool. Stool culture is negative. Colonoscopy shows continuous active inflammation with loss of vascular pattern and friability from the anal verge up to 35 cm, with a sharp cut-off
A
ULCERATIVE COLITIS
23
Q
A 46-year-old woman presents with fatigue and is found to have iron deficiency with anaemia. She has experienced intermittent episodes of mild diarrhoea for many years, previously diagnosed as irritable bowel syndrome and lactose intolerance. She has no current significant gastrointestinal symptoms such as diarrhoea, bloating, or abdominal pain. Examination reveals two oral aphthous ulcers and pallor. Abdominal examination is normal and results of faecal testing for occult blood are negative
A
COELIAC DISEASE
24
Q
A man in his early 70s presents with acute-onset, colicky, lower abdominal pain and distension, failing to pass flatus or faeces in the preceding 12 to 24 hours. He reports a recent change in his bowel habit with increased frequency of defecation, some weight loss, and the passage of blood mixed with his stools
A
LARGE BOWEL OBSTRUCTION
25
A 40-year-old man presents to his primary care physician with a 2-month history of intermittent upper abdominal pain. He describes the pain as a dull, gnawing ache. The pain sometimes wakes him at night, is relieved by food and drinking milk, and is helped partially by famotidine. He had a similar but milder episode about 5 years ago, which was treated with omeprazole
PEPTIC ULCER DISEASE
26
A 55-year-old man presents with severe dysphagia to solids and worsening dysphagia to liquids. His social history is significant for 40 pack-year cigarette smoking and a 6-pack of beer per day. He has lost over 10% of his body weight and currently is nourished only by milkshake supplements. He complains of some mild odynophagia and is constantly coughing up mucus secretions.
OESOPHAEAL CANCER
27
A 43-year-old female with a prior history of open cholecystectomy presents with gradual onset of nausea, vomiting, absolute constipation, and abdominal distention. Physical examination does not demonstrate peritonitis. Computed tomography is used to confirm the diagnosis
SMALL BOWEL OBSTRUCTION
28
A 42-year-old woman has heartburn after meals and a sour taste in her mouth. For the past 4-6 months she has had symptoms several times per week. Symptoms are worse when she lies down or bends over. Antacids help somewhat. The patient has no dysphagia, vomiting, abdominal pain, exertional symptoms, melaena, or weight loss. Past medical history and family history are non-contributory. The patient drinks alcohol occasionally and does not smoke.
GORD
29
A 25-year-old white man presents to his general practitioner with cramping abdominal pain for 2 days. He reports having loose stools and losing 6.8 kg over a 3-month duration. He also reports increased fatigue. On physical examination, his temperature is 37.6°C (99.6°F). Other vital signs are within normal limits. Abdomen is soft with normal bowel sounds and moderate tenderness in the right lower quadrant, without guarding or rigidity
CHRON'S DISEASE
30
A 57-year-old female with a history of hypertension and hypercholesterolaemia presents to the emergency department with a 24-hour history of gradually worsening left-lower quadrant abdominal pain associated with nausea and vomiting. Prior to this episode, the patient did not have any significant gastrointestinal problems, except slight constipation and occasional dyspepsia after heavy meals. She felt feverish but did not take her temperature. Her family history is negative for gastrointestinal disorders
DIVERTICULAR DISEASE
31
A 40-year-old housewife complains of recurrent constipation. She has had problems since her 20s, but they are worse now. The constipation is accompanied by abdominal bloating and abdominal pain, and the discomfort is only better when she has a bowel movement. On her gynaecologist's advice, she has tried more fibre in her diet, including fresh fruits and leafy vegetables, but that has only made the bloating worse. Her past history includes a cholecystectomy and a hysterectomy. Physical examination is entirely normal. Rectal examination reveals normal consistency stool. Stool samples test negative for occult blood.
IBS
32
A 70-year-old man presents to his primary care physician with a complaint of rectal bleeding. He describes blood mixed in with the stool, and a change from his normal bowel habit as he is going more frequently than normal. He has also experienced some crampy left-sided abdominal pain and weight loss. He has previously been fit and well and there is no family history of gastrointestinal disease. Examination of his abdomen and digital rectal examination are normal.
BOWEL CANCER
33
A 70-year-old right-handed man is discovered by a family member to have difficulty speaking and comprehending spoken language, and an inability to raise his right arm. He was last known to be fully functional 1 hour ago when the family member spoke to him by phone. There is a history of treated hypertension and diabetes.
ISCHAEMIC STROKE
34
A young boy presents to A&E with a headache, vomiting and loss of consciousness. He suffered a blow to the temple playing sports this morning with his friends earlier, despite an initial headache and drowsiness he felt fine afterwards for a few hours before these symptoms started.
EXTRADURAL HAEMATOMA
35
A 16-year-old boy presents to the emergency department with a first-time seizure event after attending an all-night party and consuming alcohol. Witnesses described the seizure as beginning abruptly with bilateral limb stiffening, followed by jerking movements in all limbs; the patient has no memory of warning symptoms prior to the seizure
GENERALISED SEIZURES
36
A 32-year-old woman presents with a 13-year history of 1-3 attacks per month of disabling pounding pain over one temple, with nausea and sensitivity to light. She says that her headaches can be triggered by lack of sleep and made worse by physical exertion, and are more common during menstrual bleeding
MIGRAINE
37
A 60-yer-old-man presents with dysarthria, dysphagia and regurgitation of fluids which can sometimes result in choking. When he talks to you, his speech is quite nasal and hoarse. On examination, his tongue is flaccid and jaw jerk is absent. His sensation is intact and normal
PROGRESSIVE BULBAR PALSY
38
A 65-year-old man presents with difficulty in decision-making and planning, which is of abrupt onset and occurs 3 months after a stroke. He has strong vascular risk factors, including smoking. Over time, there has been a fluctuating stepwise reduction in cognitive function. There is a history of nocturnal confusion and incontinence
VASCULAR DEMENTIA
39
A 25-year-old woman presents with recurrent slurring of speech that worsens when she continues to talk. She has trouble swallowing, which deteriorates when she continues to eat, and has double vision that gets worse when sewing, reading, or watching TV. She reports that her head is heavy and hard to hold up. Her symptoms have progressively deteriorated over the past 6 months. She has intermittent weakness in her legs and arms. She is fearful of falling due to her legs giving way and she has trouble combing her hair or putting on deodorant. She reports a feeling of generalised fatigue and is occasionally short of breath
MYASTHENIA GRAVIS
40
A 72-year-old white woman presents with partial vision loss in the right eye. She reports bitemporal headache for several weeks, accompanied by pain and stiffness in the neck and shoulders. Review of systems is positive for low-grade fever, fatigue, and weight loss. On physical examination, there is tenderness of the scalp over the temporal areas and thickening of the temporal arteries.
GIANT CELL ARTERITIS
41
A 28-year-old white woman who has smoked 1 pack per day for the last 10 years presents with subacute onset of cloudy vision in one eye, with pain on movement of that eye. She also notes difficulty with colour discrimination, particularly of reds. She was treated for a sinus infection 2 weeks ago and on further history recalls that she had a 3-week history of unilateral hemibody paraesthesias during examination week in university 6 years ago. She occasionally has some tingling on that side if she is overly tired, stressed, or hot.
MULTIPLE SCLEROSIS
42
A 44-year-old male smoker presents with a 9-year history of recurrent headaches. Headaches occurred twice-monthly initially, always in the early hours of the morning (2 a.m. to 3 a.m.). He always has a nocturnal event. Attacks are triggered immediately after drinking alcohol or with the smell of strong aftershave or petrol. The pain is excruciating and focused around his right eye. The right eye reddens and tears, the right eyelid droops, and the right nostril runs.
CLUSTER HEADACHE
43
A 53-year-old black woman complains of a sudden, excruciating headache while sitting at work. The headache is diffuse, intense, and accompanied by nausea and vomiting. She describes the headache as the worst headache of her life. She loses consciousness following onset of the headache and is on the floor for less than 1 minute. She is being treated for hypertension and is a smoker
SUBARACHNOID HAEMORRHAGE
44
A 70-year-old man with a history of chronic hypertension and atrial fibrillation is witnessed by a family member to have nausea, vomiting, and right-sided weakness as well as difficulty speaking and comprehending language. The symptoms started with only mild slurred speech before progressing over several minutes to severe aphasia and right arm paralysis. The patient is taking warfarin
HAEMORRHAGIC STROKE
45
An 18-year-old male student presents with severe headache and fever that he has had for 3 days. Examination reveals fever, photophobia, and neck stiffness
MENINGITIS
46
A 76-year-old white woman is brought to her general practitioner by her children because she is becoming more forgetful. She used to pay her bills independently and enjoyed cooking but has recently received overdue notices from utility companies and found it difficult to prepare a balanced meal. She has lost 3.5 kg in the past 3 months, and left the water running in her bathtub and flooded the bathroom. When her children express their concerns, she becomes irritable and resists their help. Her house has become more cluttered and unkempt
ALZHEIMER'S
47
A 37-year-old woman presents with a 12-year history of episodic headaches. She experiences these 4 times a week, typically beginning at the end of a working day. The pain is generalised and described as similar to wearing a tight band around her head. The headaches are bothersome, but not disabling, and she denies any nausea or vomiting. She is slightly sensitive to noise but has no photophobia. Pain during her attacks typically responds to ibuprofen
TENSION HEADACHES
48
A 69-year-old man presents with a 1-year history of mild slowness and loss of dexterity. His handwriting has become smaller, and his wife feels his face is less expressive and his voice softer. Over the last few months he has developed a subtle tremor in the right hand, noted while watching television. His symptoms developed insidiously but have mildly progressed. He has no other medical history, but he has noted some mild depression and constipation over the last 2 years. His examination demonstrates hypophonia, masked facies, decreased blink rate, micrographia, and mild right-sided bradykinesia and rigidity
PARKINSON'S
49
A 67-year-old man with a prior history of hypertension, diabetes, hyperlipidaemia, and a 50 pack-year smoking history noted rapid onset of right-sided weakness and subjective feeling of decreased sensation on his right side. His family reported that he seemed to have difficulty forming sentences. Symptoms were maximal within a minute and began to spontaneously abate 5 minutes later. By arrival in the accident and emergency department 30 minutes after onset, his clinical deficits had largely resolved with the exception of a subtle weakness of his right hand. Forty minutes after presentation, all of his symptoms were completely resolved.
TIA
50
A 19-year-old man presents to the emergency department with a witnessed generalised tonic-clonic seizure episode. One month previously he had an upper respiratory tract infection. Over the last 2 weeks he developed headaches, blurred vision, generalised weakness, and progressive difficulty in walking. Examination revealed pain on eye movement as well as limb and gait ataxia.
ENCEPHALITIS
51
A 25-year-old man presents to the emergency department after an automobile accident. He was ejected from the vehicle. He complains of numbness in both lower extremities and cannot move his legs. There is no pinprick sensation below the umbilicus except for an anal wink, and there is no rectal tone.
SPINAL CORD COMPRESSION
52
A young man is brought to the emergency department after being involved in a high-speed motor vehicle accident. He was an unrestrained driver, and no airbags were deployed. He has multiple areas of abrasions, lacerations, and ecchymosis on his scalp and face. On neurological examination, he does not open his eyes to painful stimuli; he is intubated, and he withdraws his left side to pain. His right side is plegic. His right pupil is 3 mm and reactive to light and his left pupil is 8 mm and non-reactive
SUBDURAL HAEMATOMA
53
A 60-year-old man presents with right foot drop, which has developed gradually over the last year and progressed to involve more proximal areas in the last 2 months. The patient reports associated muscle twitching and painful muscle cramps involving the same areas. The neurological examination reveals bilateral lower-extremity weakness, more severe on the right, with associated spasticity, atrophy of the right foot intrinsic muscles, diffuse fasciculations, and hyper-reflexia, with deep tendon reflexes being brisker on the right lower extremity, and a positive right Babinski's sign. Sensation is preserved throughout
ALS
54
A 58-year-old male teacher developed dysnomia, spelling errors, impaired comprehension of reading and conversation, and diminished singing ability. He also has impaired attention, planning, and organisation, along with declining self-care, child-like behaviour, and altered social habits (e.g., eating meals with his fingers). He developed anxiety
FRONTOTEMPORAL DEMENTIA
55
An 18-year-old girl presents with several episodes of confusion over the past several months. Typically, she experiences a warning signal, which she describes as a rising sensation within her abdomen that travels upwards through her chest. She is usually unaware for a few minutes, but others have told her that during these episodes she smacks her lips, picks at her clothing, and is unable to speak. After the event she feels tired, has a headache, and prefers to lie down
FOCAL SEIZURES - this one is temporal
56
A 54-year-old man complains of severe pain and swelling in his right first toe that developed overnight. He is limping because of the pain and states that this is the most severe pain he has ever had ('even covering my foot with the bed sheet hurts'). He has had no previous episodes. His only medication is hydrochlorothiazide for hypertension. He drinks 2 to 3 beers a day. On examination, he is obese. There is swelling, erythema, warmth, and tenderness of the right first toe. There is also tenderness and warmth with mild swelling over the mid foot
GOUT
57
A 25-year-old man presents with painful forefeet, a swollen right knee, and a swollen index finger. These symptoms developed over 2 months. He has had a history of psoriasis since the age of 18 years. Examination reveals psoriatic plaques at the knees and elbows, as well as at the posterior hair line and psoriatic nail changes of both fingers and toes. There is a dactylitis of the right index finger and several toes, as well as synovitis of the right knee
PSORIATIC ARTHRITIS
58
A 16-year-old black female presents to her general practitioner with symptoms of fatigue, musculoskeletal pain, and a facial rash. On examination she is noted to be thin with malar skin changes. No other abnormality is found.
SLE
59
A 72-year-old man is evaluated for increasing fatigue and bone pain. His medical history is significant for chronic alcoholism, lactose intolerance, and a vertebral compression fracture 1 year ago. He is housebound without any sunlight exposure. He denies any personal or family history of kidney stones, fractures, or osteoporosis. His physical examination is remarkable for generalised tenderness of the long bones and proximal muscle weakness, with difficulty climbing stairs and a waddling gait.
OSTEOMALACIA
60
A 21-year-old male student presents with a 4-week history of a painful, hot, and swollen left knee, low back pain with bilateral buttock pain, and left heel pain. He denies trauma and states the symptoms began acutely. He denies any fever or any other significant arthralgias. Further review of symptoms indicates the patient was treated for a chlamydia infection after he developed dysuria approximately 8 weeks ago (he was treated with a single dose of azithromycin). He admits to unprotected sexual intercourse with a new partner 2 days before the onset of his dysuria
REACTIVE ARTHRITIS
61
An 80-year-old man presents with a swollen red wrist, fever, and chills. He recalls falling out of his wheelchair several days ago but seemed well until 24 hours before admission, when he developed pain in his right wrist. His daughter noted fever and some confusion and brought him to the hospital. On examination, he appears ill and has a fever of 39ºC (102ºF). There is swelling, tenderness, and redness around the right wrist with oedema over the dorsum of the hand. On aspiration, they found bifringent-positive rhomboid crystals.
PSEUDOGOUT
62
A 52-year-old woman presents with a 2-month history of bilateral hand and wrist pain, and swelling in her fingers. She has also recently noted similar pain in the balls of her feet. She finds it hard to get going in the morning and feels stiff for hours after waking up. She also complains of increasing fatigue and is unable to turn on and off taps or use a keyboard at work without a significant amount of pain in her hands. On examination she has mobile, subcutaneous nodules
RHEUMATOID ARTHRITIS
63
A 20-year-old man presents to his primary care physician with low back pain and stiffness that has persisted for more than 3 months. There is no history of obvious injury but he is an avid sportsman. His back symptoms are worse when he awakes in the morning, and the stiffness lasts more than 1 hour. His back symptoms improve with exercise. He has a desk job and finds that sitting for long periods of time exacerbates his symptoms.
ANKYLOSING SPONDYLITIS
64
A 38-year-old woman sees her physician with 4 years of widespread body pain. The pain began after a motor vehicle accident and was initially limited to her neck. Gradually, the pain has spread and she now complains of hurting all over, all the time. She does not have any joint swelling or systemic symptoms. She does not sleep well and has fatigue
FIBROMYALGIA
65
A 55-year-old man complains of persistently aching legs. He is initially diagnosed with fibromyalgia. However, his blood tests reveal an elevated serum alkaline phosphatase. Subsequent x-ray of the tibia and fibula shows defects in the cortical and cancellous bone, with some degree of tibial bowing
PAGET'S DISEASE
66
A 25-year-old man who is a known intravenous drug misuser presents with a 5-day history of pain and swelling in his right leg. On examination there are multiple sites of intravenous puncture. His right leg is swollen from the knee downwards. There is a large effusion on the right knee together with significant cellulitic changes of the overlying skin
SEPTIC ARTHRITIS
67
A 70-year-old woman presents to the emergency department after falling while getting out of bed. She sustained an intertrochanteric fracture of the right hip. Preoperative chest x-ray before repair of the hip reveals that she had existing asymptomatic vertebral fractures before her fall
OSTEOPOROSIS
68
A 60-year-old woman presents complaining of bilateral knee pain almost daily for the past few months. The pain was gradual in onset. The pain is over the anterior aspect of the knee and gets worse with walking and going up and down stairs. She complains of stiffness in the morning that lasts for a few minutes, and a buckling sensation at times in the right knee. On examination, there is a small effusion, diffuse crepitus, and limited flexion of both knees. Joint tenderness is more prominent over the medial joint line bilaterally. She has a steady but slow gait, slightly favouring the right side
OSTEOARTHRITIS
69
A 40-year-old man who suffered an open tibial fracture in a motor vehicle accident 6 months ago presents with swelling and pain in his lower leg.
OSTEOMYELITIS
70
A 45-year-old man presents to the emergency department with a 1-hour history of sudden onset of left-sided flank pain radiating down towards his groin. The patient is writhing in pain, which is unrelieved by position. He is nauseous and has been vomiting
KIDNEY STONES
71
A 64-year-old man presents with painless haematuria. He had a similar episode 1 year ago and was given antibiotics for a presumed urinary infection and his bleeding resolved. He has a decreased urinary stream and nocturia twice a night. He has smoked a pack of cigarettes daily for 45 years. Physical examination shows only moderate enlargement of the prostate. Urinalysis is positive for 10 to 15 RBCs and 5 to 10 WBCs per high-power field with no bacteria detected
BLADDER CANCER
72
A 35-year-old man presents with non-specific testicular discomfort and the feeling of a mass in the testis. On examination, a 2 cm by 1 cm smooth, painless mass is palpated in the right testis. The mass does not transilluminate with light. There is no lymphadenopathy.
TESTICULAR CANCER
73
A 34-year-old woman who is otherwise healthy has had a fever, nausea, and right-sided back pain for 2 days. The physical examination shows a temperature of 39.0ºC, blood pressure of 120/60 mm Hg, pulse of 110, respiratory rate of 18, and right-sided costovertebral angle tenderness to percussion. Dipstick urinalysis is positive for leukocytes, nitrites, and blood.
ACUTE PYELONEPHRITIS
74
A 35-year-old man with no past medical history presents to the emergency department after he noted cola-coloured urine. He denies pain or fever associated with the bleed, but has had a sore throat for the past 3 days, which is getting better. He has not had a similar episode previously. Examination reveals a non-blanching purpuric rash over both his legs. There are no other abnormalities
GLOMERULONEPHRITIS
75
A 12-month-old boy presents to his primary care physician with a right scrotal mass. The mass is smaller in the morning than in the evening and increases significantly in size during crying. It gets smaller again when he is lying down. He has no gastrointestinal or urinary symptoms. Physical examination demonstrates normal findings on the left side of the scrotum and a non-tender soft swelling on the right side. The mass is transilluminated when a light is shone on the scrotum, suggesting it is fluid-filled.
HYDROCELE
76
A 30-year-old man presents with a 3-day history of a progressively diminishing urinary stream, dysuria, and urinary frequency. He denies any possibility of an STD. He is sufficiently ill with malaise and chills to require hospital admission. On examination, he is febrile with a temperature of 38.5°C (101.3°F). Digital rectal examination reveals a tender, boggy, and slightly enlarged prostate.
PROSTATITIS
77
A 54-year-old man with a 10-year history of diabetes and hypertension, with complications of diabetic retinopathy and peripheral neuropathy, presents to his primary care physician with complaints of fatigue and weight gain of 4.5 kg over the past 3 months. He denies any changes in his diet or glycaemic control, but does state that he has some intermittent nausea and anorexia. He states that he has noticed that his legs are more swollen at the end of the day but improve with elevation and rest.
CKD
78
A thin 65-year-old man with no significant past medical history presents with a 5-month history of right-sided flank discomfort and abdominal fullness. He finally seeks medical attention because of 2 weeks of lower extremity oedema, and 4 days of gross haematuria with clots. On examination, his blood pressure is 160/90 mmHg, heart rate is 120 bpm and regular, and he is afebrile. He is found to have a palpable right-sided lower abdominal mass, and pitting oedema to the mid-shins bilaterally, which is worse on the right.
RENAL CELL CARCINOMA
79
A 70-year-old man presents to his primary care physician with a 3-month history of increasing urinary frequency without burning and nocturia 3 times each evening. He has limited his fluid consumption and caffeine intake in the evening without much benefit. There is no personal or family history of prostate cancer. Examination demonstrates no suprapubic mass or tenderness. A rectal examination demonstrates normal rectal tone and a moderately enlarged prostate without nodules or tenderness.
BPH
80
A 24-year-old man presents with copious urethral discharge 4 days after having unprotected sex with a new partner. He is HIV-negative but has a history of prior STD treatments.
URETHRITIS
81
A 15-year-old boy presents with left scrotal swelling/mass detected on a routine school physical examination. The patient states that he is completely asymptomatic. There is no significant medical history and he has not had any previous surgeries. He is on no medicines and has no allergies. Physical examination in the supine position reveals asymmetrical testicular size (left smaller than right) with no masses. With the patient standing, the testes look like a bag of worms.
VARICOCELE
82
A 26-year-old female newlywed presents complaining of painful urination, feeling of urgent need to urinate, and more frequent urination for 2 days. She denies any fever, chills, nausea, vomiting, back pain, vaginal discharge, or vaginal pruritus
CYSTITIS
83
A 65-year-old male smoker with diabetes mellitus, hypertension, dyslipidaemia, and chronic kidney disease presents with chest pain. ECG changes suggest an acute myocardial infarction. He is taken for an urgent coronary angiogram. Three days later, he is noticed to have developed an elevated serum creatinine, oliguria, and hyperkalaemia
AKI
84
A 60-year-old black man presents to his general practitioner with complaints of difficulty with urination. He describes a weak stream and a sense of incomplete voiding. He describes nocturia (5 episodes per night) and has been taking an alpha-blocker for this with minimal improvement. He says he can last about 60 to 90 minutes without urinating. He denies any suprapubic tenderness, dysuria, or haematuria. He further denies any back pain or gastrointestinal complaints. Rectal examination reveals his prostate to be approximately 60 mL, asymmetrical, with a large 2-cm nodule at the right base.
PROSTATE CANCER
85
A 40-year-old man discovered that he had … about 15 years ago when he had renal colic. He was found to have bilateral stones at the time and was treated with lithotripsy. A stone was analysed. He thinks it was a uric acid stone but is not sure. He has had no further renal colic or passage of stones since that time. About 10 years ago, he developed hypertension that has been treated since with adequate control, by his account. He denies having had any UTIs. He had repair of a left inguinal hernia when he was a teenager. Recently, he had a bout of gross painless haematuria lasting 3 days and went to the emergency department for evaluation
PKD
86
A 54-year-old man with a medical history of hypertension, diabetes, dyslipidaemia, smoking, and family history of premature coronary artery disease presents with retrosternal crushing chest pain (10/10 in intensity), radiating down the left arm and left side of the neck. He feels nauseated and light-headed and is short of breath. Examination reveals hypotension, diaphoresis, and considerable discomfort with diffuse bilateral rales on chest auscultation
ACS
87
A 78-year-old man presents to his primary care physician complaining of 2 months of progressive shortness of breath on exertion. He first recognises having to catch his breath while gardening and is now unable to walk up the stairs in his house without stopping. Previously he was healthy and active without similar complaints. On physical examination there is a loud systolic crescendo-decrescendo murmur at the right upper sternal border radiating to the carotid vessels
AORTIC STENOSIS
88
An otherwise healthy 30-year-old man presents with a several-day history of progressive, severe, retrosternal chest pain that is sharp and pleuritic in nature. The pain is worse on lying down and improved with sitting forward. There is radiation to the neck and shoulders and specifically to the trapezius muscle ridges. The pain is constant and unrelated to exertion. ECG shows a saddle-shaped ST elevation
PERICARDITIS
89
A 70-year-old woman with a history of hypertension, diabetes mellitus, hyperlipidaemia, and prior myocardial infarction presents to the emergency department with palpitations and shortness of breath. These symptoms started 2 days ago. On ECG, an irregularly irregular pattern us seen with no P waves
ATRIAL FIBRILLATION
90
A 55-year-old white man presents with weakness, palpitations, and dyspnoea on exertion. On physical examination, his blood pressure is 148/50 mmHg with a bounding pulse and an early diastolic murmur over the left sternal border. He denies any history of drug abuse, rheumatic fever, or connective tissue disorder. On physical examination, there is a diastolic Austin Flint murmur.
AORTIC REGURGITATION
91
A 59-year-old man presents to the emergency department with a sudden onset of excruciating chest pain, which he describes as tearing. There is a history of hypertension. On physical examination, his heart rate is 95 beats per minute. Blood pressure is 195/90 mmHg in the right arm and 160/80 mmHg in the left arm. Pulses are absent in the right leg and diminished in the left.
AORTIC DISSECTION
92
A 78-year-old man with a history of hypertension presents to his primary care physician with 1 episode of dizziness while watching television. On physical examination, his heart rate is measured at about 40 bpm. His ECG shows a wide QRS with a notched top.
HEART BLOCK
93
A 73-year-old woman with a history of myocardial infarction presents to the accident and emergency department. She is breathless and finding it difficult to talk in full sentences. On examination she is centrally cyanosed with cool extremities. Her pulse is 110 bpm and systolic BP only just recordable at 80 mmHg. Jugular venous pressure is elevated 3 cm above normal and the cardiac apex beat is displaced. Respiratory rate is increased and she has widespread crackles and wheezes on chest examination
HEART FAILURE
94
A 50-year-old male diabetic smoker presents with leg pain on exertion for 6 months. He notes bilateral calf cramping with walking. He states that it is worse on his right calf than his left and that it goes away when he stops walking. He has noticed that distance is more limited on an incline or if stairs are present.
PERIPHERAL VASCULAR DISEASE
95
A 52-year-old woman presents with gradually increasing dyspnoea on exertion over the past 2 years. Recently she has required 2 pillows at night to alleviate recumbent dyspnoea. On examination, she has an apical mid-diastolic murmur.
MITRAL STENOSIS
96
A 55-year-old man with a history of hypertension (well controlled with medication) and tobacco use presents to his primary care physician with a 2-day history of constant and gnawing hypogastric pain. The pain has been steadily worsening in intensity. He says the pain radiates to his lower back and both groins at times. While he cannot identify any aggravating factors (such as movement), he feels the pain improves with his knees flexed. There is a palpable pulsatile mass just left of midline below the umbilicus.
AAA
97
A 64-year-old black man presents for a check-up. He denies past medical problems, but has been told that his blood pressure was a little high. He has no complaints, takes no medications, tries to adhere to a healthy diet, and rarely exercises. He reports that over the previous 5 years he has gained 6.8 kg (15 lb). Review of systems is otherwise non-contributory
HYPERTENSION
98
A 50-year-old man presents to clinic with a complaint of central chest discomfort of 2 weeks' duration, occurring after walking for more than 5 minutes or climbing more than one flight of stairs. The chest discomfort resolves with rest within several minutes. He is obese, has a history of hypertension, and smokes 10 cigarettes a day. His father died from a myocardial infarction at the age of 54 years.
STABLE ANGINA
99
A 52-year-old woman presents with dyspnoea on exertion, fatigue, and occasional palpitations. She has no prior cardiac history. She denies chest pain, orthopnoea, paroxysmal nocturnal dyspnoea, or lower extremity oedema. On physical examination her jugular venous distension is around 12 cm and her lungs are clear to auscultation. Cardiac examination reveals a slightly displaced apical impulse with a palpable P2. Cardiac auscultation reveals pansystolic whistling murmur at the apex.
MITRAL REGURGITATION
100
A 77-year-old man presents with complaints of palpitations and new shortness of breath, especially with exertion. He has a history of rheumatic fever in childhood. He has been told he has a murmur but does not recall having had an echocardiogram. He is otherwise healthy. His ECG shows a classic ‘sawtooth’ pattern.
ATRIAL FLUTTER
101
A 31-year-old woman presents with a 1-week history of fever, chills, fatigue, and unilateral ankle pain. Her past medical history includes mitral valve prolapse and hypothyroidism. She admits to infrequent intravenous heroin use and has a 10-pack-year history of smoking. Physical examination reveals temperature of 39°C (102°F), regular heart rate 110 beats per minute, blood pressure 110/70 mmHg, and respiration rate of 16 breaths per minute
INFECTIVE ENDOCARDITIS
102
A 25-year-old woman presents with a history of fatigue, ice craving, and dyspnoea upon exertion. She has three children. She did not tolerate antenatal vitamins during pregnancy, because of nausea. Examination reveals pallor and spooning of her nails. Vital signs are normal. There is no lymphadenopathy or hepatosplenomegaly
IRON DEFICIENCY ANAEMIA
103
A 65-year-old woman presents with unilateral leg pain and swelling of 5 days' duration. There is a history of hypertension, congestive heart failure, and recent hospitalisation for pneumonia. She had been recuperating at home but on beginning to mobilise and walk, the right leg became painful, tender, and swollen. On examination, the right calf is 4 cm greater in circumference than the left when measured 10 cm below the tibial tuberosity. Superficial veins on the right foot are more dilated than on the left and easily visible. The right leg is slightly redder than the left.
DVT
104
A 4-year-old girl presents with lethargy, dyspnoea, fever, and bruising. On examination she has hepatosplenomegaly. Chest x-ray shows a mediastinal mass and pleural effusion. Leukaemic blast cells are found on blood film.
ALL
105
A 24-year-old woman with known sickle cell disease presents with a 3-day history of cough productive of white sputum, nausea, and poor appetite. She also has chest and hip pain unalleviated by paracetamol or ibuprofen.
SICKLE CELL ANAEMIA
106
A 75-year-old woman presents to the emergency department with nausea, vomiting, and confusion. She has a history of low back pain of 6 months' duration and increasing sciatic pain in the last 2 weeks. On physical examination, the patient is pale and dehydrated with bone tenderness in the lumbar region. Magnetic resonance imaging reveals an L5 compression fracture. This is associated with hypercalcaemia and renal insufficiency
MULTIPLE MYELOMA
107
An 18-month-old boy presents with left ankle swelling and pain. He has limited range of motion at the ankle and has difficulty walking. Over the last year, he has presented with significant haematomas at immunisation sites. He also had prolonged bleeding after heel prick for neonatal screening tests.
HAEMOPHILIA
108
A 28-year-old man presents to his physician with a 5-day history of fever, chills, and rigors, not improving with paracetamol (acetaminophen), along with diarrhoea. He had been travelling in Central America for 3 months, returning 8 weeks ago. He had been bitten by mosquitoes on multiple occasions, and although he initially took malaria prophylaxis, he discontinued it due to mild nausea
MALARIA
109
A 20-year-old black woman presents to her primary care physician complaining of generalised weakness, fevers, and light-headedness for 2 weeks. She notes that her urine is darker than usual.
HAEMOLYTIC ANAEMIA
110
A 58-year-old man presents to his primary care physician with increasing tiredness, accompanied by bruising on his legs. He also complains of aching bones. He has no previous illnesses. On examination, he is pyrexial and pale, has bony tenderness over the sternum and tibia, and has petechiae on his legs. There are no palpable lymph nodes and his liver and spleen are enlarged. He has gum hypertrophy. After bone marrow biopsy, they find Auer rods.
AML
111
A 56-year-old woman presents with a painless right neck lump that has been slowly enlarging for the last 2 years. She denies fevers, night sweats, or weight loss. Physical examination reveals bilateral cervical and axillary adenopathy and a palpable spleen.
NON-HODGKIN'S LYMPHOMA
112
A 21-year-old Vietnamese woman presents to her general practitioner to establish care. She emigrated from Vietnam 12 years ago and has not had regular medical care in either country. She reports having chronic fatigue that interferes with her ability to complete her college studies. She has an unremarkable past medical history and has never been pregnant. She is currently sexually active. She has no siblings and her parents have no remarkable medical issues. On physical examination her liver span is 10 cm and her spleen is palpated 5 cm below the left costal margin
ALPHA THALASSAEMIA
113
A 54-year-old man presents to his primary care physician with a 2-month history of fever, malaise, and weight loss. He also reports frequent epistaxis, abdominal fullness, and early satiety. On examination, he is found to have massive splenomegaly. He is found to have the Philadelphia Chromosome on investigation.
CML
114
A 55-year-old man has had routine physical examinations for several years and has always been healthy, does not smoke, and has no history of pulmonary disease. His primary care physician has noted a gradually increasing haemoglobin level over the past few years (to a current level of 195 g/L [19.5 g/dL]), mild leukocytosis, and mild thrombocytosis. He has frequent episodes of facial flushing that are associated with slight headaches and a feeling of fullness in his head and neck.
POLYCYTHAEMIA VERA
115
A woman presents to her GP with a history of reduced reflexes, fatigue and headache. She was recently diagnosed with coeliac disease. Her daughter with her also notes that her skin seems more yellow than usual.
PERNICIOUS ANAEMIA
116
A 72-year-old man presents to his primary care physician for an annual physical. He denies any complaints such as fever or chills, weight loss, or fatigue. Of note, his blood tests show an elevated WBC count. The WBCs are predominantly lymphocytes
CLL
117
A 24-year-old woman presents to the emergency department 8 weeks postnatal with heavy vaginal bleeding, fatigue, and light-headedness. This was her first pregnancy. She has a history of menorrhagia since menarche and iron-deficiency anaemia. She had no bleeding symptoms during her pregnancy. Her father had recurrent nosebleeds as a child
VON WILLEBRAND DISEASE
118
An 8-month-old boy of Mediterranean origin presents with pallor and abdominal distension, both of which are progressive. The perinatal history was uneventful, and the boy is noted to be pale, with poor feeding, decreased activity, and failure to thrive. Hepatosplenomegaly and mild bony abnormalities of the skull are noted (frontal and parietal bossing).
BETA THALASSAEMIA
119
A 25-year-old man presents to his general practitioner with a slowly enlarging, painless right neck mass. He denies recent upper respiratory tract infections, fevers, night sweats, or unintentional weight loss. He is otherwise healthy. He does say he experiences some pain on drinking alcohol. On bone marrow biopsy, Reed-Sternberg cells are found.
HODGKIN'S LYMPHOMA
120
A 56-year-old man presents to his GP with pain in the upper-right area of his abdomen and nausea. On examination he is jaundiced and his breath smells sweet and musty. He has a past medical history of extensive cirrhosis. On investigation, his AST/ALT is raised as is his prothrombin time
LIVER FAILURE
121
A 65-year-old woman presents to the emergency department with a 2-day history of progressive right upper quadrant (RUQ) pain that she rates as 9/10. She reports experiencing fever, and being unable to eat or drink due to nausea and abdominal pain at baseline, exacerbated by food ingestion. Her bowel movements are less frequent and have become loose. Her pain is not relieved by bowel movement and is not related to food. Faecal occult blood test is negative and she has high AST/ALT and bilirubin
ASCENDING CHOLANGITIS
122
A 53-year-old man presents to the emergency department complaining of severe mid-epigastric abdominal pain that radiates to the back. The pain improves when the patient leans forwards or assumes the fetal position and worsens with deep inspiration and movement. He also complains of nausea, vomiting, and anorexia, and gives a history of heavy alcoholic intake this past week. He is tachycardic, tachypnoeic, and febrile with hypotension.
ACUTE PANCREATITIS
123
A 42-year-old man is referred to the liver clinic with mild elevation in aminotransferases for several years. He has a medical history significant for obesity, hypertension, and hypercholesterolaemia. He does not smoke or drink alcohol and there is no high-risk behaviour. He has a family history of premature cardiac disease. He is taking a diuretic and, because of his elevated liver tests, was recommended to discontinue his statin medication several months ago. Other than complaints of mild fatigue, the patient feels well. Examination is notable for a BMI of 37 kg/m², truncal obesity, and mild hepatomegaly.
NAFLD
124
A 55-year-old man presents with several episodes of haematemesis in the past 24 hours. He has a history of alcoholic cirrhosis and is being treated for ascites with diuretics and for encephalopathy with lactulose. Currently he is confused and unable to give a complete history. His vital signs include a pulse of 85 bpm and blood pressure of 84/62 mmHg. He is noted to have jaundice, splenomegaly, and multiple spider angiomas.
OESOPHAGEAL VARICES
125
A 50-year-old man with a history of obesity and heavy alcohol use presents with a 2-month history of weakness, slate-grey skin, and ascites. He is found to be a C282Y homozygote after laboratory testing shows a transferrin saturation of 76% and ferritin of 11,000 picomols/L (5000 nanograms/mL). Imaging studies demonstrate a cirrhotic-appearing liver with an ill-defined mass in the right lobe and multiple pulmonary nodules suspicious for metastases. Hepatic iron overload with metastatic hepatocellular carcinoma is confirmed at autopsy.
HAEMOCHROMATOSIS
126
A 60-year-old Asian man with a long-standing history of chronic hepatitis B virus complicated by cirrhosis presents to his primary care physician with abdominal distension, yellow eyes, right upper quadrant (RUQ) abdominal pain, decreased appetite, weight loss, and change in his sleep pattern for several weeks. Physical examination reveals a cachectic man with jaundice, palmar erythema, ascites, a palpable mass in RUQ, and asterixis.
LIVER CANCER
127
A 46-year-old obese woman presents with a 6-hour history of moderate steady pain in the right upper quadrant (RUQ) that radiates through to her back. This pain began after eating dinner, gradually increased, and has remained constant over the last few hours. She has experienced previous episodes of similar pain for which she did not seek medical advice. Her vital signs are normal. The pertinent findings on physical examination are tenderness to palpation in the RUQ without guarding or rebound.
GALLSTONES
128
A 43-year-old man with a history of mild ulcerative colitis is noted to have an elevated serum alkaline phosphatase, slightly elevated aminotransferases, and raised bilirubin on routine laboratory testing. He complains of fatigue and upper abdominal pain. He denies pruritus or fevers. Physical examination is unremarkable.
PSC
129
A 50-year-old man visits his general practitioner and complains that he has been suffering from fatigue for 2 months. The patient also reported abdominal distension and dyspnea for 2 weeks. His wife reports that the patient has recently had episodes of confusion. The patient has a significant medical history of chronic heavy alcohol use, approximately one pint of vodka per day for about 20 years. On physical examination, the patient is found to have conjunctival jaundice, tremors in both hands, and spider angiomas on the chest. Presents abdominal distention with changing dullness, ascites surge, and splenomegaly.
ALD
130
A 22-year-old American student develops severe cramping and watery stools 3 days after arriving in Guatemala. Although she avoided salads and tap water, she drank some local passion fruit juice with crushed ice before becoming ill. Frequent episodes of diarrhoea keep her confined to her hotel room. She has no underlying health problems and recovers 3 days later. Her recovery is uneventful except for several days of fatigue
INFECTIVE DIARRHOEA
131
A 39-year-old man presents for the third time in 2 years (to different physicians each time) for evaluation of an intermittent productive cough and increasing dyspnoea on exertion. He has a 15 pack-year smoking history, reports thick, yellow phlegm at times and describes having trouble keeping up when playing with his children. His medical history reveals mild intermittent asthma controlled with a salbutamol inhaler. His symptoms have persisted despite stopping smoking. He also has spider naevi and LFTs are raised.
ALPHA-1 ANTITRYPSIN DEFICIENCY
132
A 70-year-old man who smokes heavily presents with a 6-month history of intermittent abdominal pain and nausea. He has lost 10 kg of weight in the past 2 months, which he thinks is due to a decreased appetite, and he complains of pruritus. On physical examination there is icterus in the conjunctival sclerae and epigastric tenderness but no abdominal mass or lymphadenopathy. Blood tests demonstrate elevated bilirubin and alkaline phosphatase; the rest of the blood tests are within the normal range.
PANCREATIC CANCER
133
A 20-year-old obese woman with a 2-year history of gallstones presents to the emergency department with severe, constant right upper quadrant (RUQ) pain, nausea, and vomiting after eating fried chicken for dinner. She denies any chest pain or diarrhoea. Three months ago she developed intermittent, sharp RUQ pains. On physical examination she has a temperature of 38°C (100.4°F), moderate RUQ tenderness on palpation, but no evidence of jaundice.
CHOLECYSTITIS
134
A 41-year-old alcoholic man has a 6-year history of recurrent attacks of pancreatitis characterised by epigastric pain radiating to the back. The initial attack required hospitalisation for severe pain, and clinical chemistry showed a >15-fold elevation in serum amylase and lipase. Subsequent attacks were less severe, managed primarily as an outpatient, and lasted less than 10 days, with long symptom-free intervals
CHRONIC PANCREATITIS
135
A 56-year-old man with a remote history of intravenous drug use presents to an initial visit complaining of increased abdominal girth but denies jaundice. He drinks about 2 to 4 glasses of wine with dinner and recalls having had abnormal liver enzymes in the past. Physical examination reveals spider naevi, a palpable firm liver, mild splenomegaly, and shifting dullness consistent with the presence of ascites. Liver function is found to be deranged with elevated aminotransferases (aspartate aminotransferase [AST]: 90 U/L, alanine aminotransferase [ALT]: 87 U/L)
CIRRHOSIS
136
An 18-year-old woman presents with bilateral tremor of the hands. She is a senior in high school and during the year her grades have plummeted to the point that she is failing. She says her memory is now poor, and she has trouble focusing on tasks. Her behaviour has changed in the past 6 months in that she has frequent episodes of depression, separated by episodes of bizarre behaviour, including shoplifting and excessive drinking. Her parents and other authorities have begun to suspect her of using street drugs, which she denies. Her handwriting has become very sloppy. Her parents have noted slight slurring of her speech. Physical examination reveals upper extremity tremor, mild dystonia of the upper extremities and mild incoordination involving her hands. Slit-lamp examination reveals Kayser-Fleischer rings
WILSON'S DISEASE
137
A 50-year-old woman undergoing health screening is found to have a cholestatic pattern on her liver function test results. Her alkaline phosphatase and gamma-GT concentrations are elevated, although transaminases, bilirubin, and albumin concentrations are normal. On questioning she mentions that she had been getting increasingly tired over the past few years but felt that this was simply a result of her age and work pattern. She also describes occasional itch that feels as if it is deep underneath the skin and that is not associated with a rash
PBC
138
A 66-year-old man with a smoking history of one pack per day for the past 47 years presents with progressive shortness of breath and chronic cough, productive of yellowish sputum, for the past 2 years. On examination he appears cachectic and in moderate respiratory distress, especially after walking to the examination room, and has pursed-lip breathing. His neck veins are mildly distended. Lung examination reveals a barrel chest and poor air entry bilaterally, with moderate inspiratory and expiratory wheezing. Heart and abdominal examination are within normal limits. Lower extremities exhibit scant pitting oedema
COPD
139
A 65-year-old man presents to the emergency department with acute onset of shortness of breath of 30 minutes' duration. Initially, he felt faint but did not lose consciousness. He is complaining of left-sided chest pain that worsens on deep inspiration. He has no history of cardiopulmonary disease. A week ago he underwent a total left hip replacement and, following discharge, was on bed rest for 3 days due to poorly controlled pain. He subsequently noticed swelling in his left calf, which is tender on examination.
PULMONARY EMBOLISM
140
A 54-year-old smoker with multiple comorbidities (diabetes, hypertension, coronary artery disease) presents with a 2-day history of a productive cough with yellow sputum, chest tightness, and fever. Physical examination reveals a temperature of 38.3°C (101°F), BP of 150/95 mmHg, heart rate of 85 bpm, and a respiratory rate of 20 breaths per minute. His oxygen saturation is 95% at rest; lung sounds are distant but clear, with crackles at the left base. Chest x-ray reveals a left lower lobe infiltrate.
PNEUMONIA
141
A 29-year-old woman presents with shortness of breath, cough, and painful red skin lesions on the anterior surface of the lower part of both legs. CXR reveals bilateral hilar lymphadenopathy with pulmonary infiltrates.
SARCOIDOSIS
142
A 1-year-old child presents with failure to thrive. By history, the child was born at the 50th percentile for weight, but has crossed multiple percentile lines despite having a ravenous appetite. The child has more bowel movements per day than other children of the same age, and the stools often look shiny and have an unusually foul smell. In addition, the child has been treated with multiple courses of antibiotics for a persistent, wet cough. On measurement, the child is small for age, with weight and length below the third percentile
CYSTIC FIBROSIS
143
A 65-year-old patient with COPD presents to the emergency department with complaints of worsening shortness of breath and right-sided chest discomfort. He states that these symptoms occurred suddenly 1 hour prior to presentation. He denies fevers and chills. He also denies increased sputum production and a change in the colour or character of his sputum. He continues to smoke cigarettes against medical advice. The patient's blood pressure is 136/92 mmHg, heart rate is 110 beats per minute, and respiratory rate is 24 breaths per minute. Chest excursion is decreased on the right more than the left. His right hemithorax is more hyperinflated than the left. His right hemithorax is hyper-resonant on percussion. Breath sounds are distant bilaterally but more diminished on the right.
PNEUMOTHORAX
144
A 52-year-old man presents to his physician complaining of one week of progressively worsening weakness, anorexia, malaise, cough, and dark urine. He reports feeling bad for the past few weeks and thought that he was simply recovering slowly from an upper respiratory tract infection. Over the past two days he has been alarmed to notice small amounts of blood in his sputum. He has been having some shortness of breath. He has no prior personal or family history of renal disease. He has been a smoker for 30 years and he smokes a packet of cigarettes a day. He works as a car mechanic
GOODPASTURE'S
145
A 65-year-old man presents with a 2-month history of a dry persistent cough and 4.5 kg unintentional weight loss. He denies fevers, dyspnoea, sore throat, rhinorrhoea, chest pain or haemoptysis. Medical history is significant for COPD and hypertension. Family history is non-contributory. He smoked 1 pack of cigarettes daily for 40 years but quit 5 years ago. No adenopathy is palpable on examination and breath sounds are diminished globally without focal wheezes or crackles.
LUNG CANCER
146
A 55-year-old woman presents for evaluation of a chronic cough, productive of thick, yellow sputum that sometimes becomes blood-tinged. She has experienced recurrent episodes of fever associated with pleuritic chest pain. She states that she is embarrassed by the persistent, intractable nature of her cough and has been prescribed multiple courses of antibiotics. Over the last 5 years, she has developed shortness of breath with exertion. Her past medical history is significant for pneumonia as a child and sinus polyps during adulthood for which she has had surgery.
BRONCHIECTASIS
147
A 36-year-old woman presents with a 6-month history of gradually progressive dyspnoea on exertion and fatigue. On physical examination, her vital signs are normal and she appears not to be in any distress. Her lungs are clear to auscultation. Her cardiac examination shows a prominent jugular V wave, an accentuated pulmonic component to the second heart sound (P2), and a high-pitched holosystolic murmur best heard at the left sternal border
PULMONARY HTN
148
A 34-year-old man presents to his primary care physician with a 7-week history of cough that he describes as non-productive. He has had a poor appetite during this time and notes that his clothes are loose on him. He has felt febrile at times, but has not measured his temperature. He denies dyspnoea or haemoptysis. He is originally from the Philippines. He denies any history of TB or TB exposure. Physical examination reveals a thin, tired-appearing man but is otherwise unremarkable
TB
149
A 25-year-old woman presents with shortness of breath. She reported that in secondary school, she occasionally had shortness of breath and would wheeze after running. She experiences the same symptoms when she visits her friend who has a cat. Her symptoms have progressively worsened over the past year and are now a constant occurrence. She also finds herself wheezing when waking from sleep approximately twice a week.
ASTHMA
150
A 65-year-old man presents with gradually progressive dyspnoea on exertion and a non-productive cough. He has no history of underlying lung disease and no features that would suggest an alternative aetiology for his cough and dyspnoea. He has no history of joint inflammation, skin rashes, or other features of a systemic inflammatory disease such as lupus or rheumatoid arthritis. He takes no medications and has no environmental exposures to organic allergens such as mould. On examination, he has fine crackles audible over his lung bases bilaterally; however, he has no lower-extremity oedema, elevations in jugular venous pressure, or any other findings to suggest volume overload. He has clubbing of his fingers.
PULMONARY FIBROSIS
151
A 70-year-old woman presents with slowly increasing dyspnoea. She cannot lie flat without feeling more short of breath. She has a history of hypertension and osteoarthritis, and she has been taking non-steroidal anti-inflammatory drugs with increasing frequency over the previous few months. On physical examination, she appears dyspnoeic at rest, her blood pressure is 140/90 mmHg, and pulse is 90 bpm. Her jugular venous pressure is elevated to the angle of the jaw. The left lung field is dull to percussion with quiet breath sounds basally. Crackles are heard in the right lung field and above the line of dullness on the left. Lower extremities have pitting oedema to the knee
PLEURAL EFFUSION
152
A 38-year-old man presents with fever of 38.5°C (101.2°F), chills, myalgias, non-productive cough, and dyspnoea. Other than tachypnoea, tachycardia, and bibasilar rales, the rest of the physical examination is normal. He reports that this happens almost every month the day after he cleans out the bird cages in which he keeps the pigeons that he breeds and races
HYPERSENSITIVITY PNEUMONITIS
