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?