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?

Case 5

A 51 years old attending physicians is found lying on the floor of the medical record department ,after signing more than 100 charts in less than an hour. One of the residents found him and transferred him to the ER and admitted him to the ICU. On admission, he was hyponatremic, bradycardiac, with cold extremities. ECG shows ST elevation in the anterior leads with sinus Bradycardia

Laboratory studies showed

Sodium 132 meq/L

Bicarbonate 12 meq/L

Potassium 5.3 meq/L
Blood urea nitrogen 20 mg/dL

Chloride 103 meq/L

Plasma glucose130 mg/dL

1-What is the most likely clinical diagnosis?

2- How would you confirm your diagnosis? (Name two)

3-what is the best next step in management

What is the cause of death?

http://www.youtube.com/watch?v=UKekpxFrfWg

What are the possible cause of death in this case?
what would you do different if you were there in the field?

Case 4

A 50 years old male presented to the office with exertional shortness of breath and orthopnea. He exercises regularly, has no impairment of normal daily activities. Not taking any medication, with no history of allergies. He does not smoke or drink, and there is no previous medical history.

On physical examination, he looks well, not obese, afebrile, blood pressure 118/84 mmHg, pulse 68 /minutes, and respiratory rate 16 /minutes. JVP normal, no cyanosis, edema or clubbing. The rest of the physical exam was normal including cardiovascular and respiratory system.

Laboratory Studies showed no abnormalities. Chest X-ray and CT of the chest was normal, erect FEV and FVC and TLCO normal. Baseline oxygen saturation 98%

Resting and exercise ECG normal

What is the most likely clinical diagnosis?

What other investigations would you perform?

Case 3

A 71 years old male presented to the office with abdominal distention and shortness of breath. He has a history of hypertension.

On physical examination, He was afebrile, Blood pressure is 112/82 mm Hg, pulse rate is 104/minute, respiratory rate is 16 /minute, and he has severe pallor, with a significant hepatosplenomegaly.

Laboratory studies indicate a hemoglobin of 5.9 g/dl, leukocyte count of 23 × 10⁹/L, and platelet count of 235 × 10⁹/L. MCV of 78 fl,MCH of 30 pg, neutrophils 9.1x 10⁹/L,lymphocytes 6.0 x 10⁹/L,monocytes 1.2 x 10⁹/L, eosinophils 0.3x 10⁹/L, 1x 10⁹/L, basophils 0.2x 10⁹/L, metamyelocytes 4.2x 10⁹/L, myelocytes 1.2x 10⁹/L, and blast cells 0.8 x10⁹/L.

Reticulocytes < 1%. Peripheral blood smears showed tear drop cells, anisocytosis and poikocytosis

What is the most likely clinical diagnosis?

What would you do next to confirm your diagnosis?

What Anaesthetists really do ?

http://www.youtube.com/watch?v=xuZl9tRqjoQ

Case 2

A 23 years old female presented to the ER with a severe central abdominal pain associated with bilious vomiting. There was no significant past medical history, with no surgeries in the past. She is on contraceptive pills which she started recently She does not smoke, and drink alcohol occasionally. Her Father has a history of epilepsy, and her mother is diabetic.

On physical examination she was distressed secondary to severe pain. Afebrile, BP 178/105, HR 122. And RR 16. The abdomen was diffusely very tenderl, and the bowel sounds were present. The rest of the physical exam was normal.

The patient was admitted to the general medical floor and started on Intravenous normal saline, metoclopramide for the vomiting, and morphine for her abdominal pain. Next morning the nurse noticed while she was trying to insert a urinary catheter that the patient has weakness of both lower extremities. and called the intern. The intern noticed that she has left shoulder weakness exam and during the neurological exam she had a grand mal epeliptic seizure and transferred to the intensive care unit.

Laboratory evaluation shows WBC 17X10⁹/l, Hemoglobin 14 g/dl, Platelets 390x 10⁹/l, Sodium 123 meq/L, Potassium 3 meq/L, Chloride 102 meq/L Bicarb 22 meq/L Urea 15 mg/dL, serum Creatinine 1.1 mg/dL, Serum glucose 78 mg/dL Calcium 10 mg/dL, Billirubin 0.9 mg/dL, and AST, ALT 42 U/l, 44 U/L consequently

Her chest x-ray showed no evidence of acute changes. CT of the Brain and Abdomen were both normal

What is the most likely diagnosis?

How would you confirm your diagnosis?

How would you manage this patient?

How would you manage her Seizures?

Case 1

35 years old woman presented to the emergency room with sudden onset visual disturbance. On initial physical exam, she described a right hemianopic field defect which persisted for 35 minutes. Following day, she developed a mild generalized headache and neck stiffness which persisted for approximately 5 days.

She has no significant past medical history. She never smoked and there was no family history of migrane. The rest of the physical exam was normal.

The following Laboratory Studies were normal or negative: CBC, ESR, Chem 7, Lupus anticoagulant, anticardiolipin antibody, antinuclear factor and serologic test for syphilis.

1-What is the Diagnosis?

2- Which non-invasive diagnostic test would you order and why?