Case 16

A 67 year old woman with history of rheumatoid arthritis presented to the emergency department with increasing anorexia, nausea and vomiting. 4 weeks ago she had developed an itchy, erythmatous rash predominately over her trunk. This had then diminished over a period of one week. In addition she had stopped passing urine.

She had a long history of rheumatoid arthritis, and used non-steroidal anti-inflammatory drugs to control her symptoms. She did not drink alcohol, never smoked cigarette. She lives at a nursing home .She is unable to feed herself secondary to severe deformities of the small joint of her hands. She is confined to a wheelchair because of her arthritis.

On physical exam, she is afebrile, blood pressure 190/102 mm    Hg, pulse 82 /min, respiratory rate 18/min, her jugular venous pulse is elevated. Skin exam shows multiple excoriations over her trunk and extremities. Lung exam reveals bilateral. Lower extremities exam reveals moderate dependent edema. And there are obvious rheumatoid deformities in both hands. The rest of the physical exam is normal.

Labs

WBC 12 x 10⁹/l, Hemoglobin 9 g/dL, , Platelets 202 x 10⁹/l, Sodium 134meq/L
, Potassium 9.1meq/L, Chloride 98meq/L, Bicarbonate 12 meq/L, Blood urea nitrogen 47mg/dL, Serum Creatinine 6.1 mg/dL, plasma glucose 160 mg/dL. Urine analysis shows protein (+).there was 1-2 RBC /hpf.16 wbc/hpf and 6 granular and white cells casts/hpf, and no bacteria.

Renal ultrasonography shows no evidence of obstruction, and the kidneys size within normal range.

Q- What is the diagnosis?

Q What are the best next 2 steps in management

ARDS

Name two drugs which can cause ARDS.

The correct answer to case 13 is posted

Please go to Case 13

Case 15

74 years old female presented to the emergency department with worsening shortness of breath associated with abdominal distention.

On physical examination, she is afebrile, blood pressure
was 166/64 mm Hg, the heart rate 86 / minute and irregularly
irregular, the respiratory rate 18 / minute, and, Jugular venous distention
to the angle of the jaw when sitting upright was noted, as were
bibasilar rales. The apex beat of the heart was
enlarged, sustained, displaced leftward, and associated with
a right ventricular heave. There was a grade 3/6 blowing, pansystolic
murmur heard throughout the precordium, and a grade 1/6 diastolic
murmur audible at the left upper sternal border. No rubs or
gallops were heard, and there was no pericardial knock. The
patient's abdomen was distended, with a visible fluid wave,
and her liver was tender, pulsatile, and palpable 12 cm below
the right costal margin. She had peripheral edema (1+).

Echocardiogram showed evidence of tricuspid regurgitation

Which one of the following patterns 74 years old female presented to the emergency department with worsening shortness of breath in the jugular venous pulsation is typical of tricuspid regurgitation?

1. A giant A wave
   
2. A cannon wave.
   
3. A prominent C-V wave
   
4. A steep y descent.
   

Case 14

A 41 years old male with no significant past medical history presented to the emergency room with sudden onset of shortness of breath and right sided sharp chest pain. He is visiting his sister and traveled from Pakistan last week.

On physical examination, he was afebrile, blood pressure 138/84 mmHg, pulse 110 /minutes, and respiratory rate 22 /minute. The rest of the physical exam is normal.

He is not anemic and renal function is normal.

 

Q 1 –What is the best diagnostic imaging study would you use to detect emboli in the main lobar or segmental pulmonary arteries in this case?

A- Cardiac echocardiography.

B-Computed tomographic arteriography (CT)

C-Ventilation-Perfusion scanning

D-Magnetic resonance –imaging (MRI)

 

Q 2- For how long would you continue anticoagulation therapy for this patient?

A-3-6 months

B-6-9 months

C- 9-12 months

D-12 to 18 months

Case 13

A 48 years old male with presented to the emergency department with chest pain and diagnosed with acute myocardial infarction. Within one hour of presentation he develops pulmonary edema, which responds to intravenous Furosemide. The patient had cardiac angioplasty, and his chest pain resolved within 2 hours of onset. An echocardiogram shows inferior akinesa, EF 50 %, and trivial mitral regurgitation. 10 hours later, recurrent chest pain developes, and the manifestation of acute pulmonary edema return.

On physical examination, he is afebrile, blood pressure 108/64, pulse 102/min, and respiratory rate is 28/min. No jugular venous distention, cardiovascular exam reveals left sterna edge pansystolic murmur radiating to the axilla, lungs, there is rales over lower one-third of lung fields.

Q- Why did episodic pulmonary edema develop in this patient?

Case 12

A 28 years old male with no significant past medical history presented to the emergency department with a left sided chest pain of sudden onset associated with exertional shortness of breath.

On physical examination, he had clicks synchronous with the heart sounds.

What is the most likely diagnosis?

A-Pericarditis

B-Aortic Stenosis

C-Mitral valve prolapse

D-Spontaneous left side apical Pneumothorax

E-Aortic dissection

F-Pulmonary embolism

Case 11

A 28 years old male with no significant past medical history presented to the emergency room with left lower extremity swelling and tenderness secondary to dog bite. His vaccination history is up-to-date.

The intern on call did a complete evaluation and admitted the patient to the general medical floor for treatment for cellulitis.He was started on intravenous Ampicillin and sulbactam.

One hour later, the nurse on the general medical floor called urgently the intern urgently to see this patient who becomes very unwell minutes after being given intravenous Ampicillin and sulbactam. He started to wheeze and complain of chest tightness. His blood pressure is 92/60, pulse is 128/min and he is cyanosed.

 

1. What are the best next 3 steps in management? (name drug.dose,and route of administration)
   

 

Case 10

A 66 years old man with history of hypertension presented to the emergency room with a laceration over the left eyebrow and chin after he hit his head to a door he had not seen. He mentioned that he has a cloudy vision in his right eye.

Last year, he had two episodes of loss of vision in the left eye.

On physical examination, he is afebrile , blood pressure 155/90, pulse 76 /min, respiratory rate 16/min.Cardiovascular exam reveals normal first and second heart sounds, no extra heart sounds, no murmurs, and regular pulse. He had right homonoymous quadrantanopia.the rest of the physical exam is normal

He checked his random cholesterol in a health fair 3 months ago and it was elevated.

1-Locate the intracranial lesion?

2-What extracranial lesion should be ruled out first?

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Case 9

A 58 years old woman with history of hypertension, and coronary artery disease, presented to the emergency room with severe retrosternal pain, and dyspnea.

She is on Metoprolol, aspirin and Enalapril as an outpatient.

On physical examination, she is afebrile, blood pressure 142/84, pulse rate 92 /min, and respiratory rate 18/min. Cardiovascular exam reveals normal first and second heart sounds, no extra heart sounds, with no murmurs, the lungs are clear, and the peripheral pulses are equal and palpable, the rest of the physical examination is normal.ECG shows ST-segment elevation in leads II, III, and aVF. The intern on call recognized the ECG findings and called for stat cardiology consult, and activated the cardiac cath lab. Patient undergoes angioplasty with placement of bare metal stent.

Next morning patient had no complications, and asked the medical team to go home.

1-Which coronary artery is occluded in this case?

2-In addition to her outpatient medications, which medication/medications would you add and for how long?

Case 8

A 54 years old male with history of hypertension, diabetes, and recent diagnosis of lung cancer with metastasis to the liver, presented with left lower extremity swelling and tenderness. Venous ultrasonography of the lower extremities showed signs of acute deep venous thrombosis. Patient is hemodynamically and there are no signs of pulmonary embolism.

1- How would you treat this deep venous thrombosis and for how long?

Case 7

A 37 years old male with history of alcohol abuse was brought by his girlfriend to the emergency department after being found collapsed in his apartment after they had a big fight .His brother has a history of depression

On examination he was drowsy. Afebrile, blood pressure 96/60 mm Hg, pulse 132 /min, respiratory rate 18 /minutes, His pupils were dilated and reacted very sluggishly to light, with lateral tongue laceration.

Neurological exam showed hypertonia in all four extremities, reflexes were brisk, and the planters were both up going. Abdominal examination revealed a firm palpable mass 5 cm above the symphysis pubis

Lab studies: Hemoglobin 16 g/dL, Hct 43 %, platelets 295 x10⁹/l, MCV 102 fl, sodium 142 meq/L, potassium 4 meq/L, chloride 110 meq/L ,bicarbonate 20 meq/L ,urea 11mg/dL, Creatinine 1.3 mg/dL, plasma glucose 108 mg/dL, calcium 9.6 mg/L, phosphate 4 mg/dL, Billirubin 0.7 mg/dL, AST 33 U/L , alkaline phosphatase 120 U/L, plasma osmolality 338 mOsm/kg H2O, urine osmolality 122 mOsm/kg H2O

EKG revealed wide QRS, terminal right axis deviation. Prolonged QT interval and sinus tachycardia

1-What is the most likely clinical diagnosis?

2-What is the best next investigational study which is going to help you to manage this patient?

3- What are the best next 7 steps to manage this patient?

Case 5 -correct answer and comments are posted

Please go to case 5

Case 6

A 43 years old male presented to the clinic for a regular follow-up and to refill his medications.

7 months previously he had had arthritis affecting his left knee and right wrist, which responded well to treatment with non-steroidal anti-inflammatory drugs. During the past month his left ankle become swollen and painful and he had noticed breathlessness while he was shopping for an ankle bandage

He gave a history of polyuria, polydipsia, and itchy eyes for the past 4 months. He drinks s socially at weekends and smokes 20 cigarettes a day. His mother is hypertensive, and his brother has hypothyroidism

On physical examination, he was afebrile, blood pressure 132/84 mmHg, pulse 76 /minutes, and respiratory rate 14 /minute. There was conjuctival injection, on the right nostril there is erythmatous lesion with crusty margins. On lung auscultation there is inspiratory crackles in the lower base and mid zone of the right lung. Hepatomegaly, Left ankle was swollen and tender.

Laboratory studies showed

WBC 8 x 10⁹/l, neutrophils 57%,lymphocytes 39 %, eosinophils 4%, Hemoglobin 12 g/dL, Hematocrit 42%, Platelets 194 x 10⁹/l, Sedimentation rate 40 mm in first hour, Sodium 136meq/L
, Potassium 4.1meq/L, Chloride 98meq/L, Bicarbonate 16 meq/L, Blood urea nitrogen 9mg/dL, Serum Creatinine 1.1 mg/dL, plasma glucose 89 mg/dL

Joint fluid aspiration showed gram stain negative

Chest X-ray right hilar enlargement with right mid and lower zone shadowing

Sputum revealed negative cultures and negative stain for acid fast bacilli

 

1- What is the most likely clinical diagnosis?

2- What are the possible causes for his polyuria?

3-How would you confirm your diagnosis?