Vignettes

A 60-year-old man presents with acute onset of SOB, fever, and cough. CXR shows a right lower lobe infiltrate, and sputum has gram-positive diplococci. He is given IV antibiotics but his respiratory status declines over 24 hours. He becomes hypotensive and is transferred to the ICU. He is intubated for hypoxemia and requires vasopressors for septic shock despite adequate volume resuscitation. He requires high levels of inspired oxygen (FiO2) and PEEP on the ventilator to keep his oxygen saturation >90%. Repeat CXR shows bilateral alveolar infiltrates, and his PaO2/FiO2 ratio is 109.

ARDS

A 56-year-old woman with a 6- week history of weight loss, anxiety, and insomnia presents with palpitation and dyspnea. Her pulse rate is irregular at 140 to 150 bpm. Her BP is 95/55 mmHg. She looks thin, frail, and rather anxious and jittery. Her palms are sweaty and have fine tremors. She has a palpable smooth goitre. Examination of the eyes shows bilateral exophthalmoses.

Acute Atrial Fibrillation

A 65-year-old man with a history of hypertension, diabetes mellitus, and hyperlipidemia presents to the emergency room with the first episode of rapid palpitations, shortness of breath, and discomfort in his chest. These symptoms started acutely and have been present for 4 hours. Physical exam shows an irregularly irregular radial pulse at a rate between 90 and 110 bpm, BP 110/70 mmHg, and respiratory rate of 20 breaths per minute. Heart sounds are irregular, but no S3 or S4 gallop or murmurs are audible. There are no other abnormalities on examination

Acute Atrial Fibrillation

A 34-year-old woman with no known underlying lung disease has had a 12-day history of cough that has become productive of sputum. Initially she was not short of breath, but now she becomes short of breath with exertion. She initially had nasal congestion and a mild sore throat, but now her symptoms are all related to a productive cough without paroxysms. She denies any sick contacts. On physical examination she is not in respiratory distress and is afebrile with normal vital signs. No signs of URI are noted. Scattered wheezes are present diffusely on lung auscultation.

Acute Bronchitis

A patient presents with a cough that is productive of yellow/greenish thick mucous and shortness of breath that has been going on for about 2 weeks. He is positive for nasal congestion, and ill contacts. PE reveals wheezing and rhonchi bilaterally over the large airways, edematous nasal mucosa, mild erythema in the throat with no exudates.

Acute Bronchitis

A 35-year-old woman has a history of 3 consecutive pregnancy losses before 12 weeks of pregnancy. She had no other known complications during the pregnancies. Further testing reveals a lupus anticoagulant, which is still present on repeat testing 12 weeks later. Physical exam is normal.

Antiphospholipid Syndrome

A 42-year-old man is referred because of central retinal vein thrombosis. Medical history is uneventful; in particular, he has no known risk factors for venous or arterial thromboembolic disease. Screening for antiphospholipid antibodies reveals moderately elevated anticardiolipin antibody levels on 2 occasions, 12 weeks apart

Antiphospholipid Syndrome

A 78-year-old man presents to his primary care physician complaining of 2 months of progressive shortness of breath on exertion. He first recognizes 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 exam there is a loud systolic murmur at the right upper sternal border radiating to the carotids.

Aortic Stenosis

A 30-year-old man presents with fever and sore throat of 2 days' duration. He reports several months of increasing fatigue and exertional dyspnea, as well as easy bruising. Examination reveals tachycardia, evidence of tonsillopharyngitis, and scattered ecchymoses

Aplastic Anemia

A 3-year-old girl presents with a history of episodes of wheeze and troublesome cough over the past 2 years. These episodes are more common through the winter months. On 2 occasions she has been given oral corticosteroids because of severe wheeze, which was relatively unresponsive to beta-2 agonist given via MDI. In the past 6 months she has had monthly episodes of wheezing with shortness of breath, and 2 of these have resulted in need for frequent beta-2 agonist. At present she is using beta-2 agonist as required, but has used inhaled corticosteroids during the attacks in the past. Between these episodes she is well, although her mother has noted some wheeze after vigorous playing. Her father has asthma and the child herself has eczema.

Asthma

An 8-year-old boy presents with intermittent wheeze and cough, and with a history of asthma. Over recent months he has had problems with nighttime wheeze and shortness of breath. He is waking at least 3 or 4 nights per week since recovering from an upper respiratory infection. He requires his beta-2 agonist metered dose inhaler (MDI) to enable him to get back to sleep. He has also noted more problems with wheeze and shortness of breath on minimal playing at school. His general practitioner has tried cromolyn sodium and a leukotriene receptor antagonist in the past, but currently he is managed with beta-2 agonist as required. He now needs a new beta-2 agonist MDI every 2 to 3 weeks.

Asthma (Poorly Controlled)

A 76-year-old man presents with progressive symptoms of dyspnea and increasing peripheral edema. He denies palpitations. He has a history of CHF from hypertensive heart disease. He reports that he is taking his medications as directed and has had no recent medication or dietary changes.

Atrial Flutter

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.

Atrial Flutter

A 45-year-old woman seeks treatment for frequent palpitations. The patient did well throughout the first 2 decades of life. In her mid-20s she noticed that she became slightly short of breath with exertion. She has recently been seen twice in the ER for atrial tachyarrhythmias. Her left ventricular impulse is normal. Her right ventricular impulse is 2+. She has a 2/6 systolic ejection murmur at her left upper sternal border. The murmur radiates to her back. The remainder of her physical exam is normal.

Atrial Septal Defect

A 6-year-old girl is brought to her pediatrician for routine well-child care. She is doing well and has never experienced chest pain, palpitations, or syncope. She actively participates in a dance class and reports being able to keep up with her peers. There is no family history of congenital heart defects. She is well-appearing with no apparent distress. Her left ventricular impulse is normal, and there is a subtle right ventricular lift. Her second heart sound is widely split and does not vary with respiration. She has a soft 1-2/6 systolic ejection murmur best heard along the left upper sternal border. The remainder of her physical exam is normal.

Atrial Septal defect

A < 45 year old caucasian with a strong history family history of COPD presents with a prior diagnosis of COPD that is rapidly progressive.

COPD-A1-antitrypsin defciency

A 47-year-old woman presents to her oncologist with decreased exercise tolerance. She was diagnosed with breast cancer 3 years ago and has undergone radical mastectomy, radiation, and aggressive chemotherapy. Despite these measures she was diagnosed recently with metastatic disease. She seems anxious and tachypneic, has an elevated JVP, and her heart sounds are muffled. Her blood pressure is 90/50 mmHg, heart rate is 110 beats per minute, and pulsus paradoxus is 15 mmHg.

Cardiac Tamponade

A 65-year-old man without medical Hx presents with decreased exercise tolerance and progressive dyspnea at rest, beginning 3 days before presentation. He does not recall any recent illness, denies recent travel or illicit habits, and takes no medications. Over the past 24 hours he has also noted bilateral ankle edema. He is in mild distress, with a jugular venous pressure (JVP) of 13 cm and distant heart sounds. His lungs are clear and 1+ pedal edema is noted. His blood pressure is 120/80 mmHg and there is a pulsus paradoxus, which is <10 mmHg.

Cardiac Tamponade

A 70-year-old woman with a history of hypertension, diabetes mellitus, hyperlipidemia, and prior MI presents to the emergency department with palpitations and shortness of breath. These symptoms started 2 days ago. She was diagnosed to have AF with rapid ventricular rate response a year and a half ago, at which time an attempted direct current cardioversion and a trial of sotalol to maintain sinus rhythm and prevent further episodes of AF were unsuccessful. The patient was treated with digoxin and metoprolol to control rate and warfarin to prevent stroke. Current physical exam shows that she is febrile and has an irregularly irregular radial pulse at a rate between 90 and 110 bpm, BP 100/70 mmHg, and respiratory rate of 26 breaths per minute. Heart sounds are irregular, but no S3 or S4 gallop or murmurs are audible. The breath sounds are of bronchial character associated with crepitations over left basal lung area.

Chronic Atrial Fibrillation

A patient presents complaining of chronic cough with increasing mucus production. PE reveals an obese patient with a blue, bloated appearance and a noisy chest. Hgb is elevated. PFTs reveal obstruction with normal TLC. CXR reveals dirty lungs. Pulse ox indicates severe O2 desaturation.

Chronic Bronchitis

A 45-year-old man with acute onset of pancreatitis presents with episodes of epistaxis, increased PT/PTT, and decreased platelet count. Further coagulation workup reveals increased thrombin time, decreased fibrinogen level, positive D-dimers, and increased fibrin degradation products. The blood culture is negative.

DIC

A 65-year-old woman presents with unilateral leg pain and swelling of 5 days' duration. There is a history of hypertension, mild CHF, and recent hospitalization for pneumonia. She had been recuperating at home but on beginning to mobilize 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 in the leg are more dilated on the right foot and the right leg is slightly redder than the left. There is some tenderness on palpation in the popliteal fossa behind the knee.

Deep Vein Thrombosis

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 hematomas at immunization sites. He also had prolonged bleeding after heel stick for neonatal screening tests.

Hemophilia

A 65-year-old woman is admitted to a rehabilitation ward 10 days after undergoing elective right total hip arthroplasty. She had received low molecular weight heparin (LMWH) for thromboprophylaxis beginning on postoperative day 1, but intravenous heparin was subsequently started on postoperative day 9 for confirmed pulmonary embolism. Her platelet count was 175 × 10^9/L on admission to the rehabilitation ward compared with 350 × 10^9/L when intravenous heparin was initiated. Her physical exam is unremarkable except for normal postoperative changes. A venous Doppler ultrasound of her leg is negative for deep vein thrombosis.

Heparin Induced Thrombocytopenia

A 55-year-old woman presents with a left-leg deep vein thrombosis 2 days after being discharged from the hospital. She had been admitted with acute coronary syndrome and was treated with intravenous heparin for 6 days. Her platelet count has declined to 80 × 10^9/L from 250 × 10^9/L at the start of her treatment with heparin. Her physical exam is unremarkable except for left-leg edema and tenderness.

Heparin-Induced Thrombocytopenia

A 60-year-old woman has progressive dyspnea on exertion over the last 2 months. She is otherwise well with no risk factors for ischemic heart disease. Family history is significant for a cousin who died suddenly in his youth, and is otherwise unremarkable. Physical examination reveals a prominent jugular a-wave and a double apical impulse. There are no murmurs audible. An S4 is present. The remainder of the examination is normal.

Hypertrophic Cardiomyopathy

A 21-year-old active college student with no past medical history has sudden loss of consciousness, 1 hour into a game of basketball. CPR is administered by bystanders. On arrival of emergency medical professional, he has regained consciousness. The family history is significant for a murmur in his father and grandmother only. Physical examination reveals a systolic ejection murmur that increases in intensity when going from a supine to a standing position and disappears with squatting.

Hypertrophic cardiomyopathy

A 21-year-old man presents to the emergency room with CNS depression, respiratory depression, and miosis (1 mm pupils). Friends state that the patient was seen injecting something intravenously at a party, at which time he became unresponsive. He is deeply unresponsive to pain and gives no history. The patient is a known drug user. He has track marks on both upper extremities and syringes are found among his belongings.

Narcotic Overdose

42yo M; falls asleep during meetings, while watching television, and while driving. Does not feel refreshed upon awakening. lifetime nonsmoker. 2 to 3 beers on Friday nights. BP: 148/100 Pulse: 78/min BMI: 32kg/m.

Obstructive Sleep Apnea

A patient with a history of uncontrolled GERD presents complaining of morning headaches, daytime sleepiness, lack of concentration and strange vivid dreams. He thinks he's suffering from insomnia. PE reveals HTN, Cardiac dysrhythmias and a narrowed airway. What are you suspicious of?

Obstructive Sleep Apnea

A 1.5 month-old infant girl is brought to her pediatrician for poor feeding. Since she was last seen at 2 weeks she has had poor weight gain. She sweats with feeds and seems to tire out easily. There is no significant family history. On PE she is noted to be tachypneic and uninterested in her bottle after a few minutes of feeding. She has increased work of breathing. On cardiac exam, she has a grade 4 continuous murmur that is heard in the left infraclavicular region and back. She also has an early diastolic rumble best heard at the apex. Her liver is 3 cm below her costal margin. Her pulses are bounding. Her CXR reveals an enlarged heart with a prominent main pulmonary artery segment and increased pulmonary markings.

Patent Ductus Arteriosus

A 28 week premature boy is treated with appropriate doses of surfactant. However, on his second day of life he has worsening symptoms of respiratory distress syndrome with increasing ventilatory requirements. He has also started demonstrating apneic episodes. He is noted to have a widened pulse pressure (30 mmHg) on his arterial line and he is starting to have some bloody stools. On PE, he is noted to have bounding pulses and a prominent precordial impulse. On auscultation a grade 3 systolic ejection murmur can be heard in the left infraclavicular area. His abdomen also appears distended. On CXR, his lungs fields are almost completely opacified.

Patent Ductus Arteriosus

A 65-year-old man presents to the emergency department with acute onset of SOB 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. His current vital signs reveal a fever of 100.4°F (38.0°C), heart rate 112 bpm, BP 95/65 mmHg, and an O2 saturation on room air of 91%.

Pulmonary Embolism

A patient presents to the ER with acute onset of dyspnea at rest, and acute pleuritic chest pain, cough, orthopnea and calf pain. PE reveals Tachycardia, tachypnea, and decreased breath sounds. ECG reveals the S1Q3T3 pattern.

Pulmonary Embolism

A patient presents complaining of dyspnea and syncope with exertion. PE reveals Tricuspid regurgitation. A 6 minute walk screen reveals hypoxemia with exertion. What are you suspicious of?

Pulmonary Hypertension

A 70-year-old woman is 2 days postoperative for knee replacement surgery. Her past medical history includes type 2 diabetes and a 40-pack-a-year history of smoking. She reports feeling suddenly ill with dizziness, nausea, and vomiting. She denies any chest pain. On exam she is hypotensive and diaphoretic. ECG shows convex ST-segment elevation in leads II, III, and aVF with reciprocal ST segment depression and T-wave inversion in leads I and aVL.

STEMI

A middle-aged man with a medical history of hypertension, diabetes, dyslipidemia, smoking, and family history of premature CAD 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 lightheaded and is short of breath. Examination reveals a hypotensive, diaphoretic man in considerable discomfort with diffuse bilateral rales on chest auscultation. ECG reveals convex ST-segment elevation in leads V1 to V6.

STEMI

A 45-year-old man presents to the emergency department with upper abdominal pain and a history of peptic ulcer disease. He reports vomiting blood at home. He is otherwise well, takes no medications, and abstains from use of alcohol. While in the emergency department he vomits bright red blood into a bedside basin and becomes light-headed. BP is 86/40 mmHg, pulse 120 bpm, and respiratory rate 24 per minute. His skin is cool to touch, and he is pale and mottled in skin coloration.

Shock

A 72-year-old man presents with progressive malaise, weakness, and confusion. He suffers from hypertension but this is well controlled with a thiazide diuretic and an ACE inhibitor. He has diabetes, treated with metformin, but no other medical problems, and he is able to perform all activities of daily living independently. The patient's wife reports general deterioration over the last 2 days. The patient appears severely ill, weak and obtunded, unable to speak. His skin is mottled and dry with cool peripheries, and he is mildly cyanotic. Respiratory rate is 24 breaths/minute, pulse rate 94 beats/minute, BP 87/64 mmHg, and temperature 95.9°F (35.5°C). Auscultation yields coarse crackles over both lung bases.

Shock

A 24-year-old woman with known SCD 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 acetaminophen or ibuprofen.

Sickle Cell Anemia

A 6-month-old boy with no previous medical problems presents with fever and painful swelling of the hands and feet. His parents are concerned because he has been inconsolable for 6 hours. The infant has been refusing bottles and has needed fewer diaper changes over the last 2 days.

Sickle Cell Anemia

A 50-year-old man presents to clinic with a complaint of central chest discomfort after walking for more than 5 minutes or climbing more than 1 flight of stairs for the past 2 weeks. 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. On examination, his blood pressure is 144/92 mmHg with a heart rate of 82 bpm. The remainder of his exam is normal.

Stable Angina

A 60-year-old man with a history of a myocardial infarction presents to clinic for follow-up. He was started on aspirin, beta-blocker, and statin therapy after his heart attack. In the past 2 weeks the patient has noted return of chest pressure when he walks rapidly. The chest pressure resolves with sublingual nitroglycerin or a decrease in his activity level. He is a former smoker and has modified his diet and activity to achieve his goal body weight. He is normotensive on exam with a heart rate of 72 bpm. The remainder of his exam is normal.

Stable Angina

A 3-year-old boy is brought to the emergency room by his parents in the late evening. He has developed a sudden onset of a seal-like barky cough, accompanied by clear nasal discharge. His parents became alarmed when he developed stridor, which persists throughout the trip to the hospital. On examination, he has a seal-like barky cough and inspiratory stridor when at rest, which worsens with agitation. Persistent sternal indrawing is also evident at rest.

Croup

A 55-year-old factory maintenance worker falls at work. A CXR is performed to evaluate the patient for a possible broken rib. Bilateral pleural thickening is seen on CXR. Further history indicates he is very active without any respiratory symptoms. He smokes 20 cigarettes a day. There is no family history of lung disease. He does not take any respiratory medicine.

Asbestosis

A 67-year-old retired construction worker has shortness of breath with activity that has been gradually getting worse, and a chronic cough. He denies chest pain. He has a 45-pack-year smoking history, but quit at age 50. There is no family history of lung disease. He does not take any respiratory medication on a regular basis. With colds he has noticed wheezing and his doctor once prescribed an inhaler.

Asbestosis

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 exam, his heart rate is measured at about 40 bpm. A 12-lead ECG is obtained showing sinus rhythm at about 75 bpm and complete heart block with a wide junctional escape rhythm at about 40 bpm. On further questioning, the patient admits to increasing fatigue and dyspnea on exertion for the past few weeks. Notably, the patient has bifascicular block at baseline (right bundle-branch block and left anterior fascicular block).

Atrioventricular Block

A 68-year-old man presents for a routine physical exam and follow-up for his HTN, hyperlipidemia, and hypothyroidism. He complains of mild fatigue but is otherwise healthy. Laboratory evaluation is remarkable for a hematocrit of 34, with an MCV of 110 fL. On further query, he denies alcohol use or any other symptoms.

B12 Deficiency Anemia

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 Thalassemia

A patient with a history of frequent pneumonia presents complaining of productive cough with large volumes of purulent sputum. Chest X-ray/CT shows bronchial dilation and bronchial wall thickening.

Bronchiectasis

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 exam reveals a temperature of 101°F (38.3°C), 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. CXR reveals a left lower lobe infiltrate.

CAP

A 68 year-old man with a history of coronary artery disease presents with one night of shortness of breath. He went to bed and awoke gasping for air. He stood up and tried to get relief but the symptoms persisted. He denied fever. He did note that he was coughing up some whitish, frothy sputum. He also notes some swelling in both feet over the last few days. VS 98.3, BP 180/100, HR 118, RR 28, pulse ox 89% on room air. Physical exam revealed elevated JVP 12 cm, lung exam with crackles 2/3 of the way up, and heart exam that was notable for a third heart sound in mitral position

CHF

A 56-year-old woman with a history of smoking presents to her primary care physician with shortness of breath and cough for several days. Her symptoms began 3 days ago with rhinorrhea. She reports a chronic morning cough productive of white sputum, which has increased over the past 2 days. She has had similar episodes each winter for the past 4 years. She has smoked 1 to 2 packs of cigarettes per day for 40 years and continues to smoke. She denies hemoptysis, chills, or weight loss and has not received any relief from over-the-counter cough preparations.

COPD

A 66-year-old man with a smoking history of 1 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 edema.

COPD

A 2-year-old boy is brought to the emergency room by his parents in the middle of the night. He has had mild symptoms of an upper respiratory infection for 48 hours, awoke with a sudden onset of seal-like barky cough and has had inspiratory stridor when crying. The stridor disappeared at rest, but the seal-like barky cough has persisted.

Croup

A patient presents with dyspnea and cough that produces thick tenacious mucous. PFTs reveal obstructive defect. They have 2 consecutive sweat chloride tests >60 meq. What are you suspicious of?

Cystic Fibrosis

A 4-year-old boy presents to the emergency department with complaints of dysphagia, fever, drooling, and muffled voice. Symptoms have progressively worsened over the course of the day. He is toxic-appearing, and leans forward while sitting on his mother's lap. He is drooling, and speaks with a muffled "hot potato" voice. The parents deny trauma or evidence of foreign body ingestion. They have no recollection of the child receiving a Haemophilus influenzae type B (Hib) vaccine.

Epiglottitis

A 45 year old woman with six months of burning epigastric pain which is worse at night.

GERD

A 3-year-old boy was playing with colorful interlocking plastic bricks when he suddenly started coughing and gagging. The child subsequently developed a high-pitched sound and his breathing became labored. The child's caregiver called the paramedics, but while waiting for the ambulance the child's breathing slowed and he became unconscious.

FBA

An 82-year-old man suddenly choked while eating loquat fruits at home. The patient subsequently presented to the ER with a severe cough. His physical exam was normal except for localized wheezing in the right lower lung field, best heard anteriorly. There were no focal neurologic deficits and no significant past medical history. However, the patient's wife stated that he often coughed while eating.

FBA

A 70-year-old man presents for routine physical exam. He complains of fatigue, shortness of breath, and painful swallowing. He admits to daily alcohol consumption and decreased consumption of fresh vegetables and fruits. Physical exam reveals pallor, glossitis, flow murmur, and normal neurologic exam.

Folate Deficiency

A 52 year old non-smoking man presents with six months of exertional dyspnea and dry cough. Exam reveals clubbing and fine bibasilar rales

IlD

52M; persistent nonproductive cough and exertional dyspnea; difficuly accomplishing normal daily activities FEV1/FVC 87%; CT: dense fibrosis, fibroblast proliferation, and cyst formation prominent in the subpleural regions.

Idiopathic Pulmonary Fibrosis

A 50-year-old woman presents approximately 3 weeks after an upper respiratory illness with petechiae, easy bruising, and gum bleeding. She has no personal or family history of a bleeding disorder and takes no medications. Physical exam is normal except for petechiae and bruising. Specifically, she has no lymphadenopathy or hepatosplenomegaly. CBC reveals thrombocytopenia with a platelet count of 12 x 10^3/microliter but other cell lines are within normal limits. Peripheral smear shows thrombocytopenia but no other abnormalities.

Idiopathic Thrombocytopenic Purpura

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 (MVP) and hypothyroidism. She admits to infrequent intravenous heroin use and has a 10-pack-year history of smoking. Physical exam reveals temperature of 102°F (39ºC), regular heart rate 110 bpm, BP 110/70 mmHg, and respiration rate of 16 breaths per minute. Her cardiovascular exam reveals a grade 2/4 holosystolic murmur that is loudest at the right upper sternal border. Her right ankle appears red and warm, and is very painful on dorsiflexion.

Infective Endocarditis

A 19-year-old student who lived at sea level drove to approximately 8000 ft (2440 m) in the Sierra Nevada Mountains to go skiing. After spending a restless night at altitude, he awoke the next morning with a severe headache. During the day, he felt tired, did not have much appetite, and vomited after attempting to eat lunch. By the next morning, however, he felt better and was able to ski with his friends.

Mountain/Altitude Sickness

A 68-year-old man presents for a routine physical exam and follow-up for his HTN, hyperlipidemia, and hypothyroidism. He complains of mild fatigue but is otherwise healthy. Laboratory evaluation is remarkable for a hematocrit of 34, with an MCV of 110 fL. On further query, he denies alcohol use or any other symptoms.

Pernicious Anemia

A 62-year-old man, who has always been healthy, arrives for a preoperative check prior to a minor procedure. A routine CBC reveals an elevated hemoglobin level of 19.0 g/dL. He is surprised to hear about this abnormal result, as he has not noticed any symptoms or signs that have caused him concern. On exam, the only abnormality is a red facial complexion.

Polycythemia Vera

A 10-year-old female Pacific Islander presents with a 2-day history of fever and sore joints. Further questioning reveals that she had a sore throat 3 weeks ago but did not seek any medical help at this time. Her current illness began with fever and a sore and swollen right knee that was very painful. The following day her knee improved but her left elbow became sore and swollen. While in the waiting room her left knee is now also becoming sore and swollen

Rheumatic fever

A Native Hawaiian who appears to be malnourished presents complaining of chronic productive cough with blood streaking, chest pain, fever, chills, night sweats, anorexia, weight loss and fatigue. PE reveals post-tussive apical rales on lung exam. CXR reveals small, apical infiltrates

Tuberculosis

A 24-year-old woman presents to the emergency department 8 weeks postpartum with heavy vaginal bleeding, fatigue, and lightheadedness. This was her first pregnancy. She has a history of menorrhagia since menarche and iron-deficiency anemia. She had no bleeding symptoms during her pregnancy, and her vaginal bleeding was not excessive in the first few days after delivery, but it has continued since the delivery and in the past week has increased in flow. Her past medical history is remarkable for an appendectomy at age 14 years without bleeding complications, but she had to return to the oral surgeon for suturing after wisdom tooth extraction at age 16 years. Her family history is remarkable for a sister with heavy menses. Her father had recurrent nosebleeds as a child and had several cauterizations as therapy.

Von Willebrand Disease

A 21-year-old Vietnamese woman presents to her primary care physician 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 exam her liver span is 10 cm and her spleen is palpated 5 cm below the left costal margin. No lymph nodes are palpable.

Alpha-Thalassemia

A 26-year-old black woman presents in her thirteenth week of pregnancy with fatigue. She is found to be mildly anemic with a hemoglobin of 11 g/dL and an MCV of 75 fL. She is empirically started on iron sulfate tablets and develops significant constipation. Four weeks later she has had no improvement in her hemoglobin and she is referred to hematology. She has never been pregnant previously. There is no known history of anemia in her family. Her physical exam is unremarkable.

Alpha-Thalassemia

A 1-year-old boy presents with sudden-onset fever and vomiting. Findings include irritability, tachycardia, pallor, cold extremities, diffuse skin rash with abdominal petechiae, and signs of meningeal irritation. Blood tests show leukocytosis, markedly decreased platelet count, increased PT/PTT, decreased fibrinogen, elevated fibrin degradation products, elevated BUN, and metabolic acidosis. Gram-negative cocci were found in CSF and meningococci confirmed. Protein C activity is reduced.

DIC

A patient presents complaining of dyspnea. PE reveals skin that is pink and puffy, cachexia, and "quiet" chest. Labs reveal normal Hgb. PFT reveals obstruction with increased TLC and decreased DLCO. CXR reveals bullae, hyperinflation and a flattened diaphragm.

Emphysema

A 36 year old man presents with fever. He has a history of intravenous drug use which has been complicated by multiple skin abscesses at injection sites, with most recent use being two months ago. He noted first noted the fever two days ago although he has not taken his temperature. He has not noted any new rashes or skin changes. He denies other symptoms other than fatigue including cough, sputum or abdominal pain. Exam reveals a temperature of 102°F, blood pressure of 95/45, pulse of 110 and oxygen saturation of 93% on room air. Lung exam is unremarkable and cardiac exam reveals a 3/6 holosystolic murmur best heard at the 5th intercostal space in the midclavicular line, but also heard at left lower sternal border. Abdominal exam is unremarkable. Chest film is normal.

Endocarditis

A 6-year-old boy presents with prolonged bleeding after trauma to the oral cavity.

Hemophilia

A 25-year-old gravida 3 para 3 female presents with a history of fatigue, ice craving, and dyspnea upon exertion. She was unable to tolerate her prenatal 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 Anemia

A 68-year-old man presents with fatigue and dark stools. On examination his vital signs are normal but he is pale and has a rectal mass. Later biopsy of the rectal mass reveals adenocarcinoma.

Iron Deficiency Anemia

A 52-year-old woman presents with dyspnea on exertion, fatigue, and occasional palpitations. She has no prior cardiac history. She denies chest pain, orthopnea, paroxysmal nocturnal dyspnea, or lower extremity edema. On physical exam her jugular venous distension is around 12 cm and her lungs are clear to auscultation. Cardiac exam reveals a slightly displaced apical impulse with a palpable P2. Cardiac auscultation reveals III/VI holosystolic murmur at the apex that radiates to the axilla with diminished S1 and P2 greater than A2.

Mitral Regurgitation

A 42-year-old female presented to the emergency department with chest pain and shortness of breath. The week prior to presentation, she had been diagnosed with a Salmonella infection, which she acquired while on vacation. She had been treated with antibiotics, and the diarrhea she was experiencing had resolved. One day later, she developed a pressure-like sensation in the center of her chest and she had difficulty catching her breath. When she called her primary care physician, she was instructed to go to the emergency department of the nearest hospital. Her medical history was unremarkable and she had no risk factors for cardiovascular disease. Physical examination revealed her to be a thin female in no obvious distress. Blood pressure was 130/80 and pulse was 80. Lungs were clear and cardiovascular examination revealed a friction rub heard best at the left lower sternal border. The patient complained that her pain became much worse when she was asked to lie flat on the examination table. Laboratory studies were normal except for a sedimentation rate of 40 mm/hr and a CRP of 8.6 mg/L. Electrocardiogram showed diffuse PR depression in the anterolateral leads, but no signs of acute ischemia.

Pericarditis

An 80 year-old female with a history of DM, HTN presents with dyspnea, fever, cough productive of yellow sputum and scant blood for the past two days. It has been progressively getting worse. She also notes myalgias and arthralgias diffusely. Vital signs 102.4, 93/54, HR 116, RR 24, pulse ox 86% on room air. Exam revealed a normal JVP, increased breath sounds with crackles and egophony over the entire left lower lobe and normal heart exam.

Pneumonia

A 20-year-old man presents to the emergency room with complaints of left-sided chest pain and shortness of breath. He states that these symptoms began suddenly 4 days ago while he was working at his computer. He initially thought that he may have strained a chest wall muscle but, because the pain and dyspnea had not resolved, he decided to seek medical attention. He has no significant past medical history but has smoked cigarettes since the age of 16 years. His older brother suffered a pneumothorax at the age of 23 years. The patient's vital signs are normal. He appears in mild discomfort. Examination of his chest reveals that the left hemithorax is mildly hyperexpanded with decreased chest excursion. His left hemithorax is hyper-resonant on percussion, and breath sounds are diminished when compared with the right hemithorax. His cardiovascular exam is normal.

Pneumothorax

A 24 year-old man with a history of tobacco abuse (1ppd x 6 years) presents complaining of acute dyspnea. It started one hour ago and has been persistent without change. It was associated with a sharp, severe (9/10) pain in his left chest worsened by breathing. Nothing has made it better. Vital signs were 98.4, BP 90/60, HR 124, RR 32, pulse ox 88% on room air. Physical exam reveals decreased breath sounds throughout the left posterior lung field with hyperresonance to percussion

Pneumothorax

A 65-year-old patient with COPD presents to the emergency room 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 color 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

A 55-year-old man has had routine physical exams 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 hemoglobin level over the past few years (to a current level of 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. He has noted intermittent burning, stinging, and tingling sensations in his fingertips. He has recurrent, often severe, pruritus that is exacerbated by taking a hot bath. On exam, he has a red face and neck and the spleen is mildly enlarged.

Polycythemia Vera

A 65-year-old man has a history of prior anterior wall MI that occurred 2 years ago, complicated by severe left ventricular systolic dysfunction. While walking to the store, he suddenly notes palpitations, diaphoresis, dizziness, and a sense of overwhelming malaise. One minute later, he turned gray, lost consciousness, and collapsed onto the floor. An ECG revealed sustained monomorphic ventricular tachycardia at 150 bpm. image Cardiopulmonary resuscitation was initiated and the patient was cardioverted to sinus rhythm with a 200-J biphasic shock delivered from an external defibrillator. The patient regained consciousness. There was no antecedent chest discomfort and cardiac enzymes were negative after the event. Serum electrolytes were also normal. He received an implantable cardioverter/defibrillator the next day.

Sustained Ventricular Tachycardia

A 30-year-old woman presented to her primary care physician complaining of recurrent palpitations during exercise. She had previously been healthy and was on no medications. She described a long history of "skipped heart beats". Her doctor performed a treadmill exercise test, which demonstrated good effort tolerance and no evidence of ischemia. During early recovery she developed sustained monomorphic ventricular tachycardia with a left bundle branch block, inferior axis morphology. image A cardiac MRI was performed that demonstrated normal biventricular function without evidence of myocardial scar or fatty infiltration. Electrophysiologic (EP) testing was notable for inducible adenosine-sensitive ventricular tachycardia (with identical morphology to the clinical tachycardia) that was successfully ablated in the right ventricular outflow tract.

Sustained ventricular Tachycardia

A 57 year old man with a history of diabetes and hypertension presents with fever. The fever began two months ago and has been intermittent since onset. He has had a cough for approximately one month but has not produced any sputum or blood. He has also been fatigued and has lost over 20 pounds over the past two months. He has not been taking his medications as he did not seek medical care after being released from prison two years ago. He quit smoking 25 years ago. Physical examination reveals a temperature of 101.2°F, blood pressure 162/86, pulse of 99 and oxygen saturation of 93% on room air. Lungs show decreased breath sounds in the right apex but are otherwise unremarkable. Chest film shows a right upper lobe infiltrate with cavitation

TB

SOB -> severe respiratory distress PLEURITIC chest pain decreased/absent breath sounds on IPSILATERAL SIDE Hyper-resonance to percussion palpable tracheal shift hypotension and reflex tachycardia hypoxemia

Tension Pneumothorax

A 1-day-old infant in the general care nursery born at full term by uncomplicated spontaneous vaginal delivery is noted to have a murmur on exam. The baby otherwise appears well. On exam, respiratory rate is 40 and pulse oximetry is 96%. Precordium is normoactive. With auscultation, S1 is normal, S2 is single, and a 2/6 systolic ejection murmur is heard at the left upper sternal border.

Tetralogy of Fallot

A 1-day-old infant in the general care nursery born at full term by uncomplicated spontaneous vaginal delivery is noted to have cyanosis of the oral mucosa. The baby otherwise appears comfortable. On exam, respiratory rate is 40 and pulse oximetry is 80%. A right ventricular lift is palpated, S1 is normal, S2 is single, and a harsh 3/6 systolic ejection murmur is heard at the left upper sternal border.

Tetralogy of Fallot

A 42-year-old man complains of palpitations followed by dizziness and brief loss of consciousness. His wife reports that he is pale and short of breath. Emergency medical services were called and found him pulseless. The ECG revealed a rapid, irregular wide complex tachycardia. Later he was successfully resuscitated with two successive DC shocks.

WPW Syndrome

A 35-year-old man presents to an ER with palpitations, SOB, dizziness, and chest pain of 4 hours duration. An ECG demonstrated narrow-complex short RP tachycardia that responded to IV adenosine. The ECG during sinus rhythm revealed ventricular pre-excitation.

WPW Syndrome

A 65-year-old man presents with gradually progressive dyspnea on exertion and a nonproductive cough. He has no history of underlying lung disease and no features that would suggest an alternative etiology for his cough and dyspnea. He has no history of joint inflammation, skin rashes, or other features of a systemic inflammatory disease such as lupus or rheumatoid arthritis. He is on no medications and has no environmental exposures to organic allergens such as mold. On exam he has fine crackles audible over his lung bases bilaterally but no evidence of volume overload. He has clubbing of his fingers.

Usual Interstitial Pneumonia

A 72-year-old man with a history of cigarette smoking presents with mild shortness of breath. He is treated initially with inhaled bronchodilators for a presumed diagnosis of chronic obstructive lung disease but has no symptomatic improvement. PFTs are performed and show restriction rather than obstruction, and impaired diffusing capacity for carbon monoxide. A follow-up CXR shows prominent bibasilar interstitial markings.

Usual Interstitial Pneumonia