Internal Medicine EORE- Vignettes

49-year-old male who is being evaluated for pain and swelling of his right lower extremity. He noticed his calf appears red and denies any trauma to the affected area. A week prior to presentation, he was on a plane for over 13 hours. Medical history is significant for venous insufficiency. On physical exam, there is erythema on the posterior calf and tenderness along the course of a superficial vein. A duplex ultrasound demonstrates impaired blood flow and incompressibility of a superficial vein.

(Thrombo)phlebitis

63-year-old woman presents with pain in her hands for five years. She describes the pain as progressive - coming on slowly and worsening over the course of the three years. She says that her mother had problems with their hands as well. A hand X-ray is obtained which shows soft tissue swelling and marked juxta-articular osteopenia in her metacarpophalangeal and proximal interphalangeal joints, and minor bony erosions.

Rheumatoid arthritis

63-year-old illiterate female with a history of right motor partial seizures and generalization since the age of 23 years arrives at the emergency room due to acute right hemiparesis. Neurological examination reveals a right hemiparesis, right tactile and pain hypoesthesia, poor fluency, temporal and spatial disorientation, and a Mini-Mental State Examination score of 5 points (one for immediate memory, two for naming, one for repetition, and one for commands). MRI is performed demonstrating a massive AVM in the left hemisphere of the frontotemporoparietal region (9.2 × 6.0 cm) with parenchymal compression and microangiopathy.

AV malformation

23-year-old-female with a one-week history of cough productive of whitish sputum. This was preceded one week prior by a URI. She denies chills, night sweats, shortness of breath, or wheeze. Temperature is 99.9°F (37.7°C).

Acute bronchitis

69-year-old male who complains of rectal pruritus, bleeding with defecation, and a sensation of incomplete evacuation. A palpable mass is noted on digital rectal examination.

Anorectal cancer

74-y/o presents for her annual physical examination and notes increasing fatigue over the prior 3 months. Her history is notable for longstanding, but now well-controlled, systolic hypertension. A physical examination demonstrates a blood pressure of 130/70 mm Hg and an irregular pulse of approximately 120 bpm at rest. The ECG shows continuous and regular atrial activation with a sawtooth pattern, most obvious in leads II, III, and aVF.

Atrial flutter

67-year-old male presents for routine evaluation. He currently has no acute complaints and reports being otherwise well. He has a PMHx of hypertension, hyperlipidemia, and type 2 diabetes mellitus. He smokes approximately 1.5 packs of cigarettes daily for the last 29 years and drinks 2-3 12-ounce bottles of beer daily. His blood pressure is 138/90 mmHg, pulse is 82/min, and respirations are 15/min. Physical examination reveals a palpable pulsatile abdominal mass with normal pulses in the bilateral lower extremities. Ultrasonography of the abdomen demonstrates an aortic diameter of 4.2 cm.

Aortic aneurysm

73-year-old female with a history of hypertension, diabetes, and coronary artery disease presents to the emergency department with severe, tearing, knife-like back pain. She states that the pain started approximately 30 minutes ago and she has felt lightheaded and dizzy ever since its onset. On exam, her vitals are given: T: 98.6 F, HR: 115 bpm, BP: 95/53, RR: 14, SaO2: 97% on room air

Aortic dissection

61-year-old male presents with a recent history of increased fatigue with mildly increased exertional dyspnea. Patient denies any significant past medical history but states that he had some heart problems as a child, though he was never clear as to what was the problem. On cardiac examination, you hear an early diastolic, soft blowing decrescendo murmur with a high pitch quality, especially when the patient is sitting and leaning forward. No thrill is felt.

Aortic regurg

59-year-old male with chest pain, dyspnea, and presyncope. The symptoms occurred after climbing a flight of stairs. He has a late systolic-ejection murmur (SEM) heard in the second intercostal space (ICS) at the right sternal border with radiation to the carotids and the apex. The murmur is decreased with Valsalva maneuver. EKG is suggestive of LV hypertrophy. (SEM) heard in the second intercostal space (ICS) at the right sternal border with radiation to the carotids and the apex. The murmur is decreased with Valsalva maneuver. EKG is suggestive of LV hypertrophy.

Aortic stenosis

56-year-old male with a known history of polycythemia who suddenly complains of pain and paresthesia in the left leg. Physical examination reveals the left leg is cool to the touch and the toes are cyanotic. The popliteal pulse is absent by palpation and Doppler. The femoral pulse is absent by palpation but weak with Doppler. The right leg and upper extremities have 2+/4+ pulses throughout.

Arterial embolism/thrombosis

5-year-old boy who is brought to the emergency department by his parents for a cough and shortness of breath. He has a past medical history of eczema and seasonal rhinitis. On physical exam, you note a young boy in respiratory distress taking deep slow breaths to try and catch his breath. He has diminished breath sounds in all lung fields with prolonged, expiratory wheezes.

Asthma

65-year-old woman with palpitations. Her past medical history is notable for chronic obstructive pulmonary disease (COPD) for which she has been hospitalized once in the last year. On exam her T 98.4F, HR 86, BP 105/70, RR 18, SpO2 94% on room air consistent with her baseline. The ECG demonstrates low-amplitude fibrillatory waves without discrete P waves and an irregularly irregular pattern of narrow QRS complexes.

Atrial fibrillation

25-year-old cystic fibrosis patient complaining of chronic, frequent coughing productive of yellow and green sputum. She recently recovered from a Pseudomonas spp. pneumonia requiring hospitalization. On physical examination, you notice foul breath, purulent sputum, and hemoptysis along with a CXR demonstrating dilated and thickened airways with "plate-like" atelectasis (scarring).

Bronchiectasis

45-year-old woman who presents with a chief complaint of recurrent right upper quadrant pain. She reports 30-minute episodes of abdominal pain after eating meals, especially with fast food meals. She has not had any fevers or chills, and her episodes always resolve. Her past medical history includes hyperlipidemia, morbid obesity, and polycystic ovarian syndrome, for which she takes oral contraceptives. You order a right upper quadrant ultrasound, which shows gallstones without any wall thickening.You recommend conservative measures for now, including dietary changes.

Cholelithiasis

43-year-old man who comes to the emergency department because of a 3-week history of episodic cutaneous flushing, diarrhea, and wheezing. He has a past medical history of hypertension and type 2 diabetes mellitus. His temperature is 36.6°C (97.9°F), pulse is 125/min, respirations are 30/min, and blood pressure is 90/60 mm Hg. Pulmonary examination shows diffuse wheezes in both lung fields. Cardiac examination shows a prominent "v" wave of the jugular vein and a 1/6 holosystolic murmur best heard on the left lower sternal border. Abdominal examination shows hyperactive bowel sounds.

Carcinoid tumor

45 year-old male from Ireland with complaints of diarrhea, steatorrhea, flatulence, weight loss, weakness and abdominal distension. He reports having 3-5 loose stool per day for the last six months. The condition improves when he fasts.

Celiac disease

58-year-old male with acute onset of abdominal pain associated with fever and shaking chills. The patient is hypotensive and febrile with a temperature of 102.2 ° F. Although he is confused and disoriented, he complains of right upper quadrant pain during palpation of the abdomen. His sclerae are icteric and the skin is jaundiced.

Cholangitis

49-year-old female with a 2-day history of right-upper-quadrant, colicky abdominal pain, as well as nausea and vomiting. Examination shows significant pain with palpation in the right upper quadrant. Laboratory findings include an elevated WBC count, alkaline phosphatase, and bilirubin level.

Cholecystitis

56 yo female with shortness of breath, as well as a productive cough that has occurred over the past two years for at least three months each year. She is a heavy smoker. Physical exam reveals a respiratory rate of 32, slightly labored breathing, and a temperature of 98.9F. Her SpO2 is 90% while receiving oxygen via nasal cannula at 2 Lpm. (chronic bronchitis)

Chronic bronchitis

73-year-old female with complaints of heavy, restless legs and nocturnal cramping of her calves. She has a past medical history of obesity, hypertension, and previous deep venous thromboses after periods of long travel. On physical exam, her bilateral lower legs are edematous with brown hyperpigmentation around the ankles. There are no ulcers. She is scheduled for a duplex ultrasound.

Chronic venous insufficiency

53-year-old alcoholic man comes to the emergency department because of an episode of hematemesis. The patient looks disheveled and is disoriented to time and place. Past medical history includes hepatitis C infection. Abdominal examination shows abdominal distension with a fluid wave and caput medusae. Examination of the extremities shows a bilateral "flapping" tremor, red palms, and bilateral 2+ lower extremity edema.

Cirrhosis

65-year-old male with several months of weight loss, vague right upper quadrant pain, and thin-caliber stools. His medical history is notable for 50-pack-years of smoking and obesity. On exam, he appears chronically ill and has firm hepatomegaly. His labs reveal a hemoglobin of 10.7 g/dL and mildly elevated ALT and AST.

Colon cancer

65 y/o with 3 days of progressive dyspnea and purulent sputum production. The patient takes albuterol and tiotropium bromide for moderate COPD. His PMH is relevant for a 40 pack-year smoking history, type II DM, hyperlipidemia, and coronary artery stenting 2 years ago. PE shows barrel-shaped chest, inspiratory crackles, hepatojugular reflux, pulsus paradoxus, and ventricular gallop. His temperature is 38.1°C (100.5°F), his pulse is 130/min, respirations are 28/min, blood pressure is 130/84 mmHg, and pulse oximetry on room air shows an oxygen saturation of 86%.

Cop pulmonale

37-year-old male presents to the occupational health clinic after a needlestick exposure in a patient with cirrhosis. In addition to a standard bloodborne pathogen laboratory panel sent for all needlestick exposures at his hospital, additional hepatitis panels are ordered. The patient's results are shown below: HIV 4th generation Ag/Ab: Negative/NegativeHepatitis B surface antigen (HBsAg): NegativeHepatitis C antibody: NegativeAnti-hepatitis B surface antibody (HBsAb): PositiveAnti-hepatitis B core IgM antibody (HBc IgM): NegativeAnti-hepatitis B core IgG antibody (HBc IgG): Positive

Hep B

68-year-old patient who comes to the office because of increased shortness of breath for four months. His symptoms are particularly bad at night. Medical history includes long-standing hypertension and alcoholism. Examination shows a displaced apex beat and normal breath sounds. Cardiac auscultation shows an S3 gallop and a pan-systolic murmur radiating to the axilla. The chest X-ray shows an enlarged left ventricular shadow.

Dilated cardiomyopathy

67-year-old man with a long history of constipation presents with steady left lower quadrant pain. Physical exam reveals low-grade fever, mid-abdominal distention, and lower left quadrant tenderness. Stool guaiac is negative. An absolute neutrophilic leukocytosis and a shift to the left are noted on the CBC.

Diverticulitis

63-year-old male who is being evaluated in the emergency department for an episode of painless bright red blood per rectum for two hours.

Diverticulosis

25-year-old man with an 18-month history of chronic abdominal pain. The patient has seen several physicians and has been diagnosed as having a "nervous stomach," irritable bowel syndrome, and "depression." Associated with this abdominal pain for the past 3 months have been nonbloody diarrhea, anorexia, and a weight loss of 20 pounds. He has developed a painful area around the anus. On examination, the patient has diffuse abdominal tenderness. He looks thin and unwell. He has a tender, erythematous area in the right perirectal area.

Crohn disease

45-year-old female presents with burning epigastric pain that starts 2-3 hours after meals. The pain is relieved by food and antacids.

Duodenal ulcer

65-year-old male complaining of fatigue and shortness of breath with exertion. The patient reports minimal cough. On physical exam, you note a thin, barrel-chested man with decreased heart and breath sounds, pursed-lip breathing, end-expiratory wheezing, and scattered rhonchi. Chest X-ray reveals a flattened diaphragm, hyperinflation, and a small, thin appearing heart. PFTs show a decreased FEV1 / FVC ratio.

Emphysema

45-year-old female with a long history of a heart murmur with one week of increasing fatigue and low-grade fevers. She had a dental cleaning two weeks ago. She denies any hematuria, neurological symptoms, or changes in the appearance of her hands and fingernails. Her past medical history is otherwise insignificant. On physical exam, her temperature is 38.1 C (100.6 F), heart rate is 92/min, blood pressure is 118/67, and respiratory rate is 16/min. She appears fatigued but in no acute distress. Cardiac auscultation reveals a grade III/VI holosystolic murmur heard best at the cardiac apex in the left lateral decubitus position. Pulmonary, abdominal, and extremity exams are within normal limits. An echocardiogram is performed and results are pending. The patient is admitted and started on empiric IV antibiotics. Three days later, 4/4 blood cultures grow Streptococcus viridans that is highly sensitive to penicillin.

Endocarditis

62-year-old man with a history of alcoholism who complains of difficulty swallowing solids that has progressed to difficulty swallowing liquids. He has smoked 1-2 packs of cigarettes per day for the past 38 years. In addition, he reports occasional bouts of hematemesis and hoarseness, along with progressive weight loss and weakness.

Esophageal cancer

Patient will present with solid food dysphagia in a patient with a history of GERD

Esophageal stricture

64-year-old man with a history of alcoholism, tobacco use, and hypertension presents to the general surgery clinic where he was referred for further evaluation of blood in his stool. He reports occasional abdominal pain relieved transiently with meals and one episode of painful vomiting. Recently, his stools have been black. Spider angiomas, but no palmar erythema or hepatosplenomegaly are observed on the exam.

Esophageal varices

54-year-old female with odynophagia (painful swallowing), dysphagia and retrosternal chest pain

Esophagitis

55-year-old rock musician who comes to the office because he has been feeling increasingly tired for 6 months. He has a history of intravenous drug use and alcohol abuse. He states that he feels quite tired, but otherwise has no complaints. The examination is noncontributory. His laboratory investigations are normal aside from elevated liver enzymes.

Hep C

33-year-old Caucasian woman who comes to the emergency department because of vomiting and fever. The patient works as a global health nurse and her medical history is relevant for recent travel to India. Upon further questioning, the patient mentions that she is concerned because it has been 9 weeks since her last menstruation. Physical examination shows yellowing of the skin and sclera, right upper quadrant tenderness, and hepatomegaly. Her temperature is 101.3°F, pulse is 98/min, respirations are 14/min, and her blood pressure is 120/70 mmHg. Laboratory studies reveal increased aminotransferase levels and a positive pregnancy test.

Hep E

Patient will present with significant pain while having a BM, but no bleeding.

External hemorrhoids

43-year-old obese woman with a history of diabetes presents for a routine visit. She denies having any complaints. On physical exam, her physician notices mild hepatomegaly without tenderness to palpation. A liver enzyme panel is sent and reveals elevated transaminases. She is sent for a hepatic ultrasound to evaluate for nonalcoholic fatty liver disease or steatohepatitis.

Fatty liver disease

35-year-old woman who comes to your office with a 1-year history of "aching and hurting all over." She also complains of a chronic headache, difficulty sleeping, and generalized fatigue. When questioned carefully, she describes "muscle areas tender to touch." Although the pain is worse in the back, there really is no place free of pain. She also describes headaches, generalized abdomen pains, and some constipation.

Fibromyalgia

37-year-old male with a history of daily NSAID use complaining of epigastric pain, nausea, vomiting, all worsened by eating. On physical examination, he is tender to palpation in the epigastrium. He admits to drinking approximately two beers per day.

Gastritis

21-year-old bodybuilder presents with complaints of diarrhea, cramps, and low-grade fever for 24 hours. He has been training for a competition, eating large amounts of protein, including shakes made with raw eggs. He reports three thick green "pea soup" stools with blood in the commode today. He denies nausea or vomiting and tolerates liquids and solids. Examination reveals a well-muscled man in no apparent distress; lungs and heart unremarkable; abdomen, with mildly hyperactive bowel sounds and no tenderness or organomegaly; no evidence of hemorrhoids or anal fissure, no masses, and no stool present for hemoccult.

Gastroenteritis

67-year-old female with a severe throbbing headache and visual impairment in the left eye. The patient describes worsening of pain with chewing or combing her hair. Lately, she reports feeling very weak and tired especially in the mornings. At times she cannot even raise her arms to reach the cabinets in her kitchen. On physical exam, she has decreased visual acuity of the left eye, scalp tenderness on the left, and an absent pulse in the left temporal area. Laboratory testing is significant for an elevated erythrocyte sedimentation rate. She is admitted and immediately started on systemic glucocorticoids.

Giant cell arteritis

54-year-old man presents to your office with a one-day history of acute onset pain of the right knee. The patient states he has had similar episodes in the past in his metatarsophalangeal joints, which were less severe and relieved by ibuprofen. He denies any recent trauma or fever. Pertinent history includes consumption of 4-5 beers per day, sexual activity with multiple female partners over the past year, and two hospitalizations for nephrolithiasis. Physical examination shows a tender, mildly swollen, and erythematous right knee with a limited range of motion. Joint aspiration (image) shows yellow crystals in parallel to the polarization filter, and 24,200 leukocytes /µL (normal <200).

Gout

38-year-old female who has just returned from a 2-week trip to Mexico. She complains of nausea, vomiting, loss of appetite, and right upper quadrant abdominal pain. She has been sick for the past 3 days. She complains of passing dark-colored urine for the past 2 days. She has had no exposure to blood products, has no history of intravenous drug use, and has no significant risk factors for sexually transmitted disease. On examination, she looks acutely ill. Her pulse is 100 beats/minute, blood pressure 110/70 mm Hg, respirations 18, and temperature 101°F. Her sclerae are icteric, and her liver edge is tender.

Hep A

52-year-old female with a history of cirrhosis secondary to long-standing alcohol abuse visits your office to discuss a 15-pound weight loss over the last 6 months. She reports early satiety, jaundice, and vague abdominal discomfort. Her ascites, generally stable and small, has worsened in the last 3 weeks.

Liver cancer

55-year-old man who presents to the emergency room for palpitations and shortness of breath. He never had this problem before but notes that this has been progressive since he started heavy weight lifting training. He also notes regurgitation and a feeling of food being stuck before passing.

Hiatal hernia

55-year-old obese Caucasian gentleman who arrives at your clinic for a routine check-up after having some blood work done during a routing workplace health screening. He is found to have a total cholesterol level of 430 mg/dL. He complains of calf pain while walking to the convenience store, which only resolves with rest. He states that he has a follow-up appointment with his cardiologist because of some occasional chest pain and abnormalities seen on his EKG. Additionally, you notice that he has well-demarcated yellow deposits around his eyes.

Hyperlipidemia

63-year-old man who is sent to the ED by his primary care PA for hypertension. He was at a general health maintenance appointment when his blood pressure was found to be 182/122 mmHg. The patient is otherwise currently asymptomatic and states that he feels well. He has no other medical problems other than his hypertension and his labs that were drawn last week were within normal limits. At the ED his temperature is 97.3°F, blood pressure is 198/110 mmHg, pulse is 82/min, respirations are 16/min, and oxygen saturation is 99% on room air. Physical exam is unremarkable. Labs at the ED are significant for a serum creatinine of 2.4 mg/dL.

Hypertensive emergency

63-year-old man who is sent to the ED by his primary care PA for hypertension. He was at a general health maintenance appointment when his blood pressure was found to be 182/122 mmHg. The patient is otherwise currently asymptomatic and states that he feels well. He has no other medical problems other than his hypertension and his labs that were drawn last week were within normal limits. At the ED his temperature is 97.3°F, blood pressure is 198/110 mmHg, pulse is 82/min, respirations are 16/min, and oxygen saturation is 99% on room air. Physical exam is unremarkable. Labs at the ED are within normal limits.

Hypertensive urgency

25-year-old man is brought to the ED because he collapsed while playing tennis 20 minutes ago. Medical history includes unexplained chest pain and shortness of breath while exercising for three years. Family history includes an uncle who died of an unknown cardiac pathology at the age of 23. Cardiac auscultation shows a 2/6 systolic murmur is heard at the left of the sternum between the first two ribs. The murmur becomes louder when the patient performs a Valsalva maneuver and decreases with squatting.

Hypertrophic cardiomyopathy

40-year-old woman who comes to your office with a several-year history of lower abdominal pain associated with constipation (one hard bowel movement every 3 days) and frequent mucous discharge. She states that her abdominal pain is better after a bowel movement. She has never passed blood per rectum. She describes no fever, chills, weight loss or gain, jaundice, or any other symptoms. There is no relationship between the abdominal pain and specific food intake. On physical examination, the abdomen is scaphoid, and no hepatosplenomegaly or masses are palpated. There is a mild generalized abdominal tenderness, but it does not localize.

IBS

55-year-old female who is a current smoker presents with a 9-month history of respiratory symptoms, including dyspnea on exertion, thoracic pain, and dry cough, which were preceded by a pulmonary infection. On auscultation, you hear inspiratory crackles. Pulmonary function tests (PFTs) show only mild impairment of vital capacity with decreased lung volume and a normal to increased FEV1/FVC ratio.

Idiopathic pulmonary fibrosis

43-year-old who has recently noticed bright red blood on the toilet paper when he wipes. He denies any fatigue, decreased exercise tolerance, abdominal pain, or maroon-colored or black, tarry stools. He has no family history of colon cancer. He has never had a colonoscopy. On physical exam, his temperature is 98.6 F, heart rate 70/min, and blood pressure 120/75 mmHg. He does not have conjunctival pallor. There are no abnormalities on cardiac, pulmonary, and abdominal exams.

Internal hemorrhoids

32-year-old male presents to your clinic for evaluation of a recent onset of dizziness that occurred while he was upright and was generally associated with exertion. This especially concerned him since he was working as a bricklayer. During one episode at work, he found himself down on the floor but was not sure if he actually passed out. The patient smokes one pack of cigarettes per day and drinks four to six beers daily on the weekend. On physical examination, his blood pressure is 145/88 and his HR is 64 bpm and regular. He is modestly overweight, with a distribution of fat consistent with a beer belly. A 12-lead ECG showed sinus rhythm, rate 60, with an R and R' (upward bunny ears) in V4-V6. There were no previous ECGs immediately available.

LBBB

60-year old caucasian male with shortness of breath and fatigue on exertion. On physical exam, you note an S3 heart sound, crackles on pulmonary auscultation, and a displaced left apical impulse. He undergoes an echocardiogram and is found to have a dilated left ventricle and an ejection fraction of 35%.

LV failure

21-year-old male with hematemesis. He is brought by his girlfriend who reports that he and his buddies have been out drinking every night last week in celebration of his 21st birthday. He reports having vomited each night, but tonight when he started vomiting, he noticed that there was streaking of blood. Concerned, he decided to come to the emergency department.

Mallory-Weiss tear

64-year-old obese man with a history of hyperlipidemia and poorly controlled type 2 diabetes underwent percutaneous transluminal coronary angioplasty of the posterior descending artery 3 days ago for an ST-elevation myocardial infarction. He has so far been stable since this procedure, but overnight you are called to his bedside. He is pallid and breathing laboriously. Notable vital signs include a blood pressure of 85/45 mmHg with a heart rate of 125 beats per minute. His lung exam is notable for bibasilar crackles. On cardiac exam, you note a hyperactive precordium with a new III/VI blowing holosystolic murmur at the apex (mitral area) with a split S2 that radiates to the axilla.

Mitral regurg

72-year-old female who presents to your office for a routine check-up. While she otherwise feels well, it has been a long time since she last received medical care. On exam her you note an apical, rumbling diastolic murmur with a split s1 that occurs following an opening snap. The rumbling is loudest at the start of diastole and is heard best at the left sternal border and apex. She has no other physical exam findings and has no other past medical history.

Mitral stenosis

22-year-old female who complains of generalized, sub-sternal chest pain that is worsened with exertion. She appears anxious; she denies ETOH, tobacco, and illicit drug use. You auscultate her heart and hear a midsystolic click

Mitral valve prolapse

72-year-old man is admitted for exacerbation of COPD. On the third day, he reports dizziness associated with occasional chest pain. His telemetry reveals an irregular rhythm with a pulse of 124/min. The EKG demonstrates an irregularly irregular rhythm, rate of 120 bpm, discrete P waves before every QRS complex with 4 different P wave morphologies.

Multifocal atrial tachycardia

64-year-old man comes to the emergency department because of chest discomfort for the past 5 hours. When the patient is asked where the pain is located, he places a clenched fist to indicate a squeezing over his substernal region. The pain radiates to the neck, left shoulder, and left arm. His temperature is 36.8°C (98°F), pulse is 55/min, respirations are 17/min, and blood pressure is 117/78 mm Hg. The examination shows a diaphoretic male. ECG shows inverted U-waves in leads V5 and V6. The cardiac biomarker test shows an elevated concentration of troponin.

NSTEMI

68-year-old smoker with a 25 lb weight loss over the last three months that is associated with a burning pain deep in the epigastrium after eating, diarrhea, and jaundice. Physical exam reveals a palpable non-tender gallbladder and clay-colored stool. Labs show total bilirubin of 8, alkaline phosphatase of 450, and an ALT of 150.

Pancreatic cancer

37-year-old male complaining of rapid onset of severe mid-epigastric pain with radiation to the back after eating a large meal. The pain typically lessens when the patient leans forward or lies in the fetal position. Physical exam shows low-grade fever, epigastric tenderness, diminished bowel sounds, and bruising of the flanks. An abdominal CT scan shows localized dilation of the upper duodenum and a small collection of fluid in the left pleural cavity.

Pancreatitis

65-year old man who presents to the ED at 1 am with 90 minutes of central chest pressure that awoke him from sleep. He says he thinks he has 'indigestion.' The pain is non-radiating, with mild shortness of breath but no nausea, vomiting or diaphoresis. He is an ex-smoker with a 20 pack-year history. There is no previous history of CAD, diabetes, hypertension, or high cholesterol. On arrival, he looks well, with a normal heart rate (54 bpm), blood pressure (127/86), and oxygen saturation (98% on room air). His pain has improved slightly with sublingual nitrates in the ambulance, although he still has some ongoing chest discomfort. His ECG is shown below. Troponins are positive. He is admitted to the hospital and undergoes emergent cardiac catheterization, where he is without obstructive coronary disease, but his symptoms can be provoked with the administration of intravenous ergonovine.

Prinzmetal angina

45-year-old male with type I diabetes mellitus and end-stage renal disease currently on hemodialysis presents to the emergency department with dyspnea, cough and chest pain. He describes the pain as worse during inspiration and when he is lying on his back.

Pericarditis

63-year-old male complaining of bilateral leg pain, which has been increasing gradually over the past several months. It worsens when he walks but improves with rest. Past medical and surgical history is significant for hypertension, hyperlipidemia, and coronary artery bypass graft (5 years ago). He has a 60-pack-year smoking history. Vital signs are as follows: Temp 37C, HR 70, BP 143/89, and RR 18. Physical exam of the lower extremities reveals palpable but weak posterior tibial and dorsalis pedis pulses bilaterally; they are warm and well perfused. Ankle-brachial indices are 0.7 and 0.8.

Peripheral artery disease

53-year-old man presents to the office complaining of progressive dyspnea over the past few years. History reveals that he has worked in construction for the past 20 years demolishing and refurbishing old buildings. He rarely uses any protective breathing equipment. Physical examination demonstrates an afebrile man in mild respiratory distress with inspiratory crackles. The chest x-ray reveals a reticular linear pattern with basilar predominance, opacities, and honeycombing. (asbestosis)

Pneumoconiosis

71-year-old male who was admitted to the acute care hospital two days following a massive CVA with a possible brainstem infarct. Because he was also experiencing secondary respiratory failure, he was intubated and placed on mechanical ventilation. He was subsequently transferred to the neurointensive care unit where he was stabilized. His present vital signs are respiratory rate 14 (ventilator rate), temperature 100.4 F. His SpO2 is 95%. His rating on the Glasgow Coma Scale is 5.

Pneumonia

45-year-old male with generalized symptoms such as malaise, fever, sore throat, and joint and muscle aches and pains. He also complains of numbness, tingling, sensory disturbances, and weakness. On physical examination, you notice the presence of tender lumps under the skin, especially on the thighs and lower legs. Laboratory testing is notable for a newly elevated creatinine of 2.6 mg/dL, erythrocyte sedimentation rate, and C-reactive protein. He is also seropositive for hepatitis B virus, ANCA-negative, and guaiac positive.

Polyarteritis nodosa

62-year-old female complaining of headaches, muscle pain, and weakness. She has no history of headaches but has now started experiencing them every morning for the past two weeks. She reports feeling very weak and tired in the mornings and cannot even raise her arms to brush her hair. Physical exam shows that she has normal strength and a normal range of movement. Her passive range of motion is limited in all directions and she has difficulty rising out of the exam room chair. The erythrocyte sedimentation rate is elevated.

Polymyalgia rheumatica

47-year-old female with a complaint of feeling unusually tired and weak. She works as a hairstylist and in the past few weeks has experienced difficulty performing her job. She finds it difficult to work while she has her arms raised. She denies any fevers, weight gain or loss, or any other motor deficits. Physical exam reveals decreased strength in her shoulders. No rash is appreciated. Laboratory evaluation reveals increased creatinine phosphokinase, positive antinuclear antibody, and positive anti-JO 1 antibodies. She is started on high-dose corticosteroids.

Polymyositis

Male patient with a history significant for ulcerative colitis who has been stable and free of problems for over 7 years. He describes worsening symptoms of fatigue, pruritus, anorexia, and indigestion over the past 6 months. His wife reports that his skin and eyes appear yellow although she adamantly denies alcohol consumption. Labs reveal an elevated alkaline phosphatase, mild elevations in AST and ALT. ERCP fails to show common bile duct obstruction.

Primary sclerosing cholangitis

59-year-old woman complaining of severe left hip pain for the past day. She states the hip feels warm and looks enlarged. The patient has had multiple similar episodes in her knees, hips, and wrists over the last few years, for which she took ibuprofen as needed. Past medical history is significant for hypertension and type II diabetes mellitus, which are well managed with lisinopril and metformin, respectively. Vital signs are within normal limits. Physical examination shows an erythematous and swollen left hip joint. It is tender to palpation with decreased active and passive range of motion. Arthrocentesis of the left hip is performed. Gram stain is negative. Polarized light microscopy shows rhomboid-shaped, weakly positively birefringent crystals.

Pseudogout

43-year-old woman with a history of COPD presents to the office with worsening dyspnea, especially at rest. She also complains of dull, retrosternal chest pain. On examination, she has persistent widened splitting of S2. Radiographic findings (seen here) demonstrate peripheral "pruning" of the large pulmonary arteries.

Pulmonary hypertension

65-year-old woman with a 40 pack-year history of smoking presents with a 7 kg weight loss over the last 3 months and recent onset of streaks of blood in the sputum. PE reveals a thin, afebrile woman with clubbing of the fingers, an increased anteroposterior diameter, scattered and coarse rhonchi and wheezes over both lung fields, and distant heart sounds.

Pulmonary neoplasm

35-year-old female who was found to have a small (2.5 cm) pulmonary lesion on chest radiograph found incidentally after a screening exam for a positive PPD at work. The patient has no significant past medical history and is asymptomatic.

Pulmonary nodules

24-year-old male with dyspnea on exertion. Physical exam reveals a high pitched decrescendo murmur at the LUSB that increases with inspiration

Pulmonary regurg

25-year-old male who presents to the clinic complaining of mild dyspnea on exertion. Examination reveals a prominent jugular pulsation and a palpable parasternal lift. There is a harsh systolic murmur best heard at the second and third left intercostal space; it radiates to the left shoulder. An early systolic sound precedes the murmur during expiration. ECG demonstrates right-axis deviation

Pulmonic stenosis

64-year-old male with a history of coronary artery disease, hypertension, hyperlipidemia, and type II diabetes with increasing shortness of breath and ankle swelling over the past month. On physical examination, you note jugular venous distention, increased hepatojugular reflex, and hepatomegaly. His lungs are clear to auscultation.

RV failure

23-year-old male with redness of the eye as well as discharge. He reports that he experiences pain with urination and stiffness and pain in the knee and ankle. With further questioning, he reports a history of gonorrhea infection that was diagnosed and treated approximately 5 weeks ago. He is otherwise healthy. On physical exam, there is conjunctivitis, asymmetric oligoarthritis, and discharge from the urethral meatus.

Reactive arthritis

58-year-old man complaining of several months of worsening shortness of breath and ankle swelling. He denies palpitations, lightheadedness, syncope, or chest pain. He has a past medical history significant for hereditary hemochromatosis. On physical exam, his temperature is 37 C (98.6 F), pulse is 78, blood pressure is 130/72 mm Hg, and respiratory rate is 16. He has elevated jugular venous pressure, diminished breath sounds at the lung bases, tender hepatomegaly, and bilateral pitting ankle edema. There are no murmurs, rubs, or gallops. EKG shows low-voltage QRS complexes without any signs of ischemia. His chest x-ray shows a normal-sized heart and bilateral pleural effusions. Echocardiography shows symmetrical thickening of the left ventricle, normal left ventricular volume, and mildly reduced systolic function.

Restrictive cardiomyopathy

30-year-old woman presents with 2 weeks of arthralgias, migrating from distal to proximal joints. It began with increased warmth and erythema in her right ankle and left knee. She has a low-grade fever and reports a history of sore throat and swollen glands about 1 month ago. On physical exam she has red skin lesions on the trunk and proximal extremities, and also small, non-tender lumps located over the joints. Antistreptolysin O titer is positive.

Rheumatic fever

60-year-old man is brought to the emergency department because of crushing substernal chest pain for the past 45 minutes. He received 325 mg of aspirin en route. Nitroglycerin does not relieve his pain. He has a history of diabetes and hypertension. Medications include carvedilol and sildenafil. His temperature is 36.8°C (98°F), pulse is 99/min, respirations are 18/min, and blood pressure is 192/88 mm Hg. He appears diaphoretic. ECG shows ST-segment elevation in leads V1, V2, and V3.

STEMI

30-year-old African American female with a cough, fever, and generalized body aches. You order a CXR which shows bilateral hilar adenopathy.

Sarcoidosis

45- year-old male admitted to the hospital because of several months of sudden onset of recurrent weakness accompanied by flushing of the face and dizzy spells. The patient also had recurrent spells of chest pain localized to the sternal area. The symptoms last for 10-15 seconds and sometimes 30 seconds to a minute and go away without treatment. During his stay in the ICU, the patient had similar symptoms several times and the monitor showed long periods of asystole with no ventricular activity. This was associated with blood pressure drops and the patient felt dizzy. The echocardiogram is within normal limits.

Sick sinus syndrome

55-year-old female patient complaining of inability to eat completely due to loss of teeth. Along with that the patient also complains of dryness of mouth, for 1 year, and dryness of eyes for 7-8 years. Extraoral examination showed bilateral parotid gland enlargement present on the right and left side of the parotid region.

Sjogren syndrome

50-year-old woman with a history of hyperlipidemia and diabetes type 2 complaining of "chest pain attacks." She says that these attacks tend to occur while walking up five flights of stairs to get to her apartment, they last for 15-20 minutes and are relieved by rest. She describes the pain as sharp and substernal. A baseline EKG is unremarkable. Suspecting the diagnosis, you perform an exercise stress EKG and observe transient ST depressions in the anterolateral leads after significant exertion.

Stable angina

68-year-old man, who presents to your clinic with complaints of fatigue, loss of appetite, and abdominal pain/fullness. He reports a 15-pound weight loss over the last three months. Vital signs are within normal limits. On exam, you discover a firm, enlarged painless lymph node above the patient's left clavicle. Upon further questioning, the patient reports the node has been present for the past 2 months. His stool is Guaiac positive

Stomach cancer

44-year-old female with intermittent joint pain. The joint pain began about 13 months ago affecting primarily the joints in her hands, wrists, and feet. She expresses concern regarding worsening fatigue, muscle aches, and feelings of depression. The physical exam reveals tender, edematous bilateral wrists; painless oral ulcers; and erythematous maculopapular lesions on her face.

Systemic lupus erythematosus

73-year-old man with a history of rheumatic fever and coronary atherosclerosis who presents to the emergency department with dyspnea on exertion and orthopnea. He called 911 because he could not catch his breath. On examination, he was found to have jugular venous distention (JVD), hepatic congestion, and peripheral edema. A blowing holosystolic murmur along the left sternal border that is intensified during a Valsalva maneuver and inspiration is noted. Atrial fibrillation is noted on his ECG.

Tricuspid regurg

Patient has a diastolic rumbling murmur heard best at the left lower sternal margin and the xiphoid, augmented during inspiration

Tricuspid stenosis

32-year-old woman comes to your office with a 6-month history of loose bowel movements, approximately eight per day. Blood has been present in many of them. She has lost 30 pounds. For the past 6 weeks, she has had intermittent fever. She has had no previous gastrointestinal (GI) problems, and there is no family history of GI problems. On examination, the patient looks ill. Her blood pressure is 130/ 70 mm Hg. Her pulse is 108 beats/ minute and regular. There is generalized abdominal tenderness with no rebound. A sigmoidoscopy reveals a friable rectal mucosa with multiple bleeding points.

Ulcerative colitis

58-year-old man with a history of coronary artery disease, hypertension, and hyperlipidemia who presents to an emergency department for evaluation of chest pain. He reports somewhat suddenly experiencing dull left-sided chest discomfort while at rest at home that was not relieved with taking nitroglycerin. His vital signs are T 37.1, HR 94 beats per minute, BP 133/87, and O2 saturation 97% on room air. His ECG shows no ST-segment changes; serum troponin is not elevated. His chest pain subsequently resolves and he is admitted to the cardiac service for further management.

Unstable angina

77-year-old Hispanic female with a dull ache in her legs that is worsened with prolonged standing and relieved with rest and elevation of her legs. She has fourteen grown children and a past medical history of obesity and hypertension. On physical exam, her bilateral lower legs are edematous with multiple dilated, tortuous superficial veins.

Varicose veins

78-year-old female complaining of generalized pain and edema in her left leg. She denies chest pain, shortness of breath, and hemoptysis. She takes 2.5 mg warfarin daily for atrial fibrillation and her INR is 2.6. On physical examination the patient experience calf pain with dorsiflexion of the left foot. The patient has a positive D-dimer, and a lower extremity ultrasound reveals the presence of a deep venous thrombosis in the left popliteal vein.

Venous thrombosis

4-year-old boy who is brought to your office by his parents because he gets tired very easily and cannot keep up with the other children. On exam, you hear a loud, harsh, holosystolic murmur at the left lower sternal border without radiation to the axillae.

Ventricular septal defect

68-year-old female who arrives at the emergency department after a syncopal episode at work. Physical exam reveals an obese, unresponsive female with bilateral nonpalpable radial, carotid, and distal pedal pulses. Vital signs are as follows: T 99.4 F and BP 88/47.

Ventricular tachycardia

25-year-old female patient with complaints of sudden onset of a pounding heartbeat, which is regular and "too rapid to count." She reports that the episodes begin and terminate abruptly and are associated with shortness of breath and chest discomfort. On exam, the patient appears anxious, her heart rate is 170 bpm. EKG demonstrates a shortened PR interval, widened QRS, and delta waves.

WPW