Cases Flashcards
Simulate cases
A 56-year-old man comes to the emergency department (ED) complaining of chest discomfort. He describes the discomfort as a severe, retrosternal pressure sensation that had awakened him from sleep 3 hours earlier. He previously had been well but has a medical history of hypercholesterolemia and a 40-pack-year history of smoking. On examination, he appears uncomfortable and diaphoretic, with a heart rate of 116 bpm, blood pressure of 166/102 mm Hg, respiratory rate of 22 breaths per minute, and oxygen saturation of 96% on room air. Jugular venous pressure appears normal. Auscultation of the chest reveals clear lung fields, a regular rhythm with an S4 gallop, and no murmurs or rubs. A chest radiograph shows clear lungs and a normal cardiac silhouette.
The electrocardiogram (ECG) shows ST elevation.
A 72-year-old man presents to the clinic complaining of several weeks of worsening exertional dyspnea. Previously, he had been able to work in his garden and
mow the lawn, but now he feels short of breath after walking 100 ft. He does not have chest pain when he walks, although in the past, he has experienced episodes
of retrosternal chest pressure with strenuous exertion. Once recently he had felt light-headed, as if he were about to faint while climbing a flight of stairs, but the
symptom passed after he sat down. He has been having some difficulty in sleeping at night and has to prop himself up with two pillows. Occasionally, he wakes
up at night feeling quite short of breath, which is relieved within minutes by sitting upright and dangling his legs over the bed. His feet have become swollen,
especially by the end of the day. He denies any significant medical history, takes no medications, and prides himself on the fact that he has not seen a doctor in
years. He does not smoke or drink alcohol.
On physical examination, he is afebrile, with a heart rate of 86 bpm, blood pressure of 115/92 mm Hg, and respiratory rate of 16 breaths per minute. Examination
of the head and neck reveals pink mucosa without pallor, a normal thyroid gland, and distended neck veins. Bibasilar inspiratory crackles are heard on examination.
On cardiac examination, his heart rhythm is regular with a normal S1 and a second heart sound that splits during expiration, an S4 at the apex, a nondisplaced apical
impulse, and a late-peaking systolic murmur at the right upper sternal border that radiates to his carotids. The carotid upstrokes have diminished amplitude.
Congestive Heart Failure
A 58-year-old man comes to your office, because of shortness of breath. He has experienced mild dyspnea on exertion for a few years, but more recently he has
noted worsening shortness of breath with minimal exercise and the onset of dyspnea at rest. He has difficulty reclining; as a result, he spends the night sitting up in a chair trying to sleep. He reports a cough with production of yellowish-brown sputum every morning throughout the year. He denies chest pain, fever, chills,
or lower extremity edema. He has smoked about two packs of cigarettes per day since age 15. He does not drink alcohol. A few months ago, the patient went to an
urgent care clinic for evaluation of his symptoms, and he received a prescription for some inhalers, the names of which he does not remember. He was also told to
find a primary care physician for further evaluation. On physical examination, his blood pressure is 135/85 mm Hg, heart rate is 96 bpm, respiratory rate is 28 bpm,
and temperature is 97.6°F. He is sitting in a chair, leaning forward, with his arms braced on his knees. He appears uncomfortable with labored respirations and
cyanotic lips. He is using accessory muscles of respiration, and chest examination reveals wheezes and rhonchi bilaterally, but no crackles are noted. The anteroposterior diameter of the chest wall appears increased, and he has inward movement
of the lower rib cage with inspiration. Cardiovascular examination reveals distant heart sounds but with a regular rate and rhythm, and his jugular venous pressure is normal. His extremities show no cyanosis, edema, or clubbing.
COPD
A 44-year-old man presents with sudden onset of shaking chills, fever, and productive cough. He was in his usual state of good health until 1 week ago, when
he developed mild nasal congestion and achiness. He otherwise felt well until last night, when he became fatigued and feverish, and developed a cough associated with right-sided pleuritic chest pain. His medical history is remarkable only for his 15-pack per year smoking habit. In your office, his vital signs are normal except for a temperature of 102°F. His oxygen saturation on room air is 100%. He is comfortable, except when he coughs. His physical examination is unremarkable except for
bronchial breath sounds and end-inspiratory crackles in the right lower lung field.
Pneumonia
A 49-year-old woman presents to the emergency department (ED) complaining of a 4-week history of progressive abdominal swelling and discomfort. She has no other gastrointestinal symptoms, and has a normal appetite and normal bowel habits. Her medical history is significant only for three pregnancies, one of which was complicated by excessive blood loss, requiring a blood transfusion. She has been married and monogamous for 20 years, exercises, does not smoke, and drinks only occasionally. On pointed questioning, however, she does admit that she was “wild” in her youth, and she had snorted cocaine once or twice at parties many years ago. She does not use drugs now. She was HIV negative at the time of the birth of her last child.
On examination, her temperature is 100.3°F, heart rate is 88 bpm, and blood pressure is 94/60 mm Hg. She is thin, her complexion is sallow, her sclerae are icteric, her chest is clear, and her heart rhythm is regular with no
murmur. Her abdomen is distended, with mild diffuse tenderness, hypoactive bowel sounds, shifting dullness to percussion, and a fluid wave. She has no
peripheral edema.
Laboratory studies are normal except for Na 129 mEq/L
(normal 135-145), albumin 2.8 g/dL (normal 3.5-5 g/dL), total bilirubin 4 mg/dL,
prothrombin time 15 seconds (normal 11-13.5), hemoglobin 12 g/dL with
mean cell volume (MCV) 102 fL (normal 78-95), and platelet count 78,000/mm3
(normal 150,000-500,000).
Cirrhosis, Probable Hepatitis C–Related
A 28-year-old man comes to your clinic complaining of a 5-day history of nausea,
vomiting, diffuse abdominal pain, fever to 101°F, and muscle aches. He has lost his
appetite, but he is able to tolerate liquids and has no diarrhea. He has no significant medical history or family history, and he has not traveled outside the United
States. He admits to having 12 different lifetime sexual partners, denies illicit drug
use, and drinks alcohol occasionally, but not since this illness began. He takes no
medications routinely, but he has been taking acetaminophen, approximately
30 tablets per day for 2 days for fever and body aches since this illness began.
On examination, his temperature is 100.8°F, heart rate is 98 bpm, and blood pressure is 120/74 mm Hg. He appears jaundiced, his chest is clear to auscultation,
and his heart rhythm is regular without murmurs. His liver percusses 12 cm, and
is smooth and slightly tender to palpation. He has no abdominal distention or
peripheral edema.
Laboratory values are significant for a normal complete blood
count, creatinine 1.1 mg/dL, alanine aminotransferase (ALT) 3440 IU/L, aspartate
aminotransferase (AST) 2705 IU/L, total bilirubin 24.5 mg/dL, direct bilirubin
18.2 mg/dL, alkaline phosphatase 349 IU/L, serum albumin 3.0 g/dL, and prothrombin time 14 seconds.
Acute Viral Hepatitis, Possible Acetaminophen
Hepatotoxicity
You are the intern on call in the hospital when the emergency center resident calls up a new admission. She describes an 84-year-old Alzheimer patient who was
brought to the emergency room by ambulance from her long-term care facility for increased confusion, combativeness, and fever. Her medical history is significant for Alzheimer disease and well-controlled hypertension; otherwise she has been very healthy. The resident states that the patient is “confused” and combative with staff, which, per her family, is not her baseline mental status. Her temperature is 100.5°F, heart rate is 130 bpm, blood pressure is 76/32 mm Hg, respiratory rate is 24 bpm, and oxygen saturations is 95% on room air. On examination, she is
lethargic but agitated when disturbed, her neck veins are flat, her lung fields are
clear, and her heart rhythm is tachycardic but regular with no murmur or gallops.
Abdominal examination is unremarkable and her extremities are warm and pink.
After administration of 2 L of normal saline over 30 minutes, her blood pressure is now 95/58 mm Hg, and the initial laboratory work returns.
Her white blood cell
count (WBC) is 14,000/mm3, with 67% neutrophils, 3% bands, and 24% lymphocytes.
No other abnormalities are noted. Chest x-rays obtained in the emergency room are
normal. Urinalysis shows 2+ leukocyte esterase, negative nitrite, and trace blood.
Microscopy shows 20 to 50 white blood cells per high-power field, 0 to 3 red blood
cells (RBCs), and many bacteria.
Urinary Tract Infection
A 62-year-old man is brought to the clinic for a 3-month history of unintentional weight loss (12 lb). His appetite has diminished, but he reports no vomiting or
diarrhea. He does report some depressive symptoms since the death of his wife a year ago, at which time he moved from Hong Kong to the United States to live with his daughter. He denies a smoking history. He complains of a 3-month history of productive cough with greenish sputum. He has not felt feverish. He takes no
medications regularly. On examination, his temperature is 100.4°F and respiratory rate is 16 bpm. His neck has a normal thyroid gland and no cervical or supraclavicular lymphadenopathy. His chest has few scattered crackles in the left mid-lung fields and a faint expiratory wheeze on the right. His heart rhythm is regular with no gallops or murmurs. His abdominal examination is benign, his rectal examination shows no masses, and his stool is negative for occult blood.
His chest xray is significant for upper lobar infiltrates.
Tuberculosis
While seeing patients in your preceptor’s clinic, you have the opportunity to meet
and examine one of her long-time patients, a 52-year-old woman who presents
for her yearly physical examination. She has been fine and has no complaints
today. Her medical history is notable only for borderline hypertension and moderate obesity. Last year her fasting lipid profile was acceptable for someone without
known risk factors for coronary artery disease. Her mother and older brother have
diabetes and hypertension. At prior visits, you see that your preceptor has counseled her on a low-calorie, low-fat diet and recommended that she start an exercise
program. However, the patient says she has not made any of these recommended
changes. With her full-time job and three children, she finds it difficult to exercise,
and she admits that her family eats out frequently. Today her blood pressure is
140/92 mm Hg. Her body mass index (BMI) is 29 kg/m2
. Her examination is notable
for acanthosis nigricans at the neck but otherwise is normal. A Papanicolaou (Pap)
smear is performed, and a mammogram is offered. The patient has not eaten yet
today, so on your preceptor’s recommendation, a fasting plasma glucose test is
performed, and the result is 140 mg/dL.
Type 2 Diabetes Mellitus
An 18-year-old woman is brought to the emergency department by her mother because the daughter seems confused and is behaving strangely. The mother
reports the patient has always been healthy and has no significant medical history, but she has lost 20 lb recently without trying and has been complaining of
fatigue for 2 or 3 weeks. The patient had attributed the fatigue to sleep disturbance, as recently she has been getting up several times at night to urinate. This
morning, the mother found the patient in her room, complaining of abdominal pain, and she had vomited. She appeared confused and did not know that today
was a school day. On examination, the patient is slender, lying on a stretcher with eyes closed, but she is responsive to questions. She is afebrile, and has a heart rate of 118 bpm, blood pressure of 125/84 mm Hg, with deep and rapid respirations at the rate of 24 bpm. Upon standing, her heart rate rises to 145 bpm, and her blood pressure falls to 110/80 mm Hg. Her funduscopic examination is normal, her oral mucosa is dry, and her neck veins are flat. Her chest is clear to auscultation, and her heart is tachycardic with a regular rhythm and no murmur. Her abdomen is soft with active bowel sounds and mild diffuse tenderness, but no guarding or rebound.
Her neurologic examination reveals no focal deficits.
Laboratory studies include serum Na 131 mEq/L, K 5.3 mEq/L, Cl 95 mEq/L, CO2 9 mEq/L, blood urea nitrogen (BUN) 35 mg/dL, creatinine 1.3 mg/dL, and glucose 475 mg/dL. Arterial blood gas reveals pH 7.12 with PCO2 24 mm Hg and PO2 95 mm Hg. Urine drug screen and urine pregnancy test are negative, and urinalysis shows no hematuria or pyuria, but 3+ glucose and 3+ ketones. Chest radiograph is read as normal, and plain film of the abdomen has nonspecific gas pattern but no signs of obstruction
Diabetic Ketoacidosis
A 37-year-old previously healthy woman presents to your clinic for unintentional
weight loss. Over the past 3 months, she has lost approximately 15 lb without
changing her diet or activity level. Otherwise, she feels great. She has an excellent
appetite, no gastrointestinal complaints except for occasional loose stools, a good
energy level, and no complaints of fatigue. She denies heat or cold intolerance. On
examination, her heart rate is 108 bpm, blood pressure 142/82 mm Hg, and she
is afebrile. When she looks at you, she seems to stare, and her eyes are somewhat
protuberant. You note a large, smooth, nontender thyroid gland and a 2/6 systolic
ejection murmur on cardiac examination, and her skin is warm and dry. There is a
fine resting tremor.
Graves Disease/Thyroid Storm
A 58-year-old man arrives at the emergency department complaining of chest pain.
The pain began 1 hour ago, during breakfast, and is described as severe, dull, and
pressure-like. It is substernal in location, radiates to both shoulders, and is associated with shortness of breath. The patient vomited once. His wife adds that he was
very sweaty when the pain began. The patient has diabetes and hypertension and
takes hydrochlorothiazide and glyburide. His blood pressure is 150/100 mm Hg,
pulse rate is 95 beats per minute, respiration is 20 breaths per minute, temperature 37.3°C (99.1°F), and oxygen saturation by pulse oximetry is 98%. The patient
is diaphoretic and appears anxious. On auscultation, faint crackles are heard at
both lung bases. The cardiac examination reveals an S4
gallop and is otherwise
normal. The examination of the abdomen reveals no masses or tenderness.
ECG shows no ST elevations.
NSTEMI
A 19-year-old man is brought to the emergency department (ED) with diffuse
abdominal pain, vomiting, and altered level of consciousness. The patient’s symptoms began several days ago, when he complained of “the flu.” His symptoms
at that time included profound fatigue, nausea, mild abdominal discomfort and
some urinary frequency. Today he was found in bed moaning but otherwise unresponsive. His past medical history is unremarkable, and he is currently taking
no medications. On physical examination, the patient appears pale and ill. His
temperature is 36.0°C (96.8°F), pulse rate is 140 beats per minute, blood pressure
is 82/40 mm Hg, and the respiratory rate is 40 breaths per minute. His head and
neck examination shows dry mucous membranes and sunken eyes; there is an
unusual odor to his breath. The lungs are clear bilaterally with increased rate and
depth of respiration. The cardiac examination reveals tachycardia, no murmurs,
rubs, or gallops. The abdomen is diffusely tender to palpation, with hypoactive
bowel sounds and involuntary guarding. The rectal examination is normal. Skin
is cool and dry with decreased turgor. On neurologic examination, the patient
moans and localizes pain but does not speak coherently.
Laboratory studies: the
leukocyte count is 16,000 cells/uL, and the hemoglobin and hematocrit levels are
normal. Electrolytes reveal a sodium of 124 mEq/L, potassium 3.4 mEq/L, chloride 98 mEq/L, and bicarbonate 6 mEq/L. BUN and creatinine are mildly elevated.
The serum glucose is 740 mg/dL (41.1 mmol/L). The serum amylase, bilirubin,
AST, ALT, and alkaline phosphatase are within normal limits. A 12-lead ECG shows
sinus tachycardia. His CXR is normal.
DKA
A 73-year-old woman is brought to the emergency department (ED) from an
assisted-living facility. The patient has a history of dementia, hypertension, and
type II diabetes mellitus. By report, she has had chills and a productive cough
for several days. In the past 24 hours she has become weaker and does not want
to get out of bed. The physical examination reveals a thin, elderly woman who is
somnolent but arousable. Her rectal temperature is 36.0°C (96.8°F), pulse rate
is 118 beats per minute, blood pressure is 84/50 mm Hg, and respiratory rate is
22 breaths per minute. Her mucous membranes are dry. Her heart is tachycardic
but regular. She has crackles at her right lung base with a scant wheeze. Her abdomen is soft and nontender. The extremities feel cool and her pulses are rapid and
thready. The patient is moving all extremities, without focal deficits.
Sepsis
A 70-year-old woman is transferred from a nursing home to the emergency department (ED) due to fever and shortness of breath. Per her daughter, the patient
has had a productive cough for 2 days and became more short of breath and less
responsive earlier today. The patient’s past medical history is significant for diabetes mellitus, hypertension, and high cholesterol. Her vital signs include temperature 38.9°C (102.1°F), heart rate 104 beats per minute, blood pressure 130/85 mm
Hg, respiratory rate 28 breaths per minute, and room air oxygen saturation 91%
(96% with 3-L oxygen by nasal cannula). On examination, she is awake but slow to
answer questions. The daughter states that her mother is usually more alert than
this. Her skin is dry and warm to touch. Her heart sounds are regular and mildly
tachycardic without any S3
or S4
. On auscultation, she has rhonchi at the right lung
base. She does not have any jugular venous distention, lower extremity edema, or
calf tenderness.
Pneumonia
