LONG CASES

Patient 1. (15 points)

For the past nine months a 57-year-old carpenter had not felt really well. He had struggled to work, but was becoming increasingly tired and found it difficult to concentrate for a full day. He noticed some swelling of the ankles in the evening, and his gums and nose bled slightly in the mornings. His appetite was poor. His urine was dark in the mornings, but the stools were a normal color.

Four weeks previously he had suffered influenza with the rest of his family, but afterwards he found his abdomen increasing in size so that he could not zip up his pants. His weight had increased. He slept poorly and sometimes had difficulty in holding a cup in the morning. His wife noticed his breath was occasionally unpleasant. He denied excessive consumption of alcohol, he had never suffered from hepatitis and he took no regular drugs. There was no family history of liver disease. He ate a good diet. He had never received a blood transfusion.

He weight was 80 kg (his usual weight was 70 kg). His temperature was 37 °C. His blood pressure was 100/70. His complexion was muddy. His eyes were slightly yellow and his cheeks sunken. The tongue was dry and furred, and fetor hepaticus was present. Small vascular spiders were seen on the face, neck, shoulders and hands. The palms were red and mottled. There was a coarse tremor of the outstretched hands. He had difficulty in remembering recent events and in performing mental arithmetic. The JVP was raised 4 cm above the sternal angle. The circulation was hyperdynamic with an apical systolic murmur also heard in the axilla. In contrast to a very distended abdomen, the limbs were spindly. The abdominal distension was particularly in the flanks, the umbilicus was everted. The skin was shiny. Distended abdominal veins were seen around the umbilicus, the direction of flow being away from the navel. Shifting dullness could be detected and there was no abdominal tenderness. Tendon reflexes were brisk and the plantar responses flexor. Pitting edema of the ankles was present. Sexual hair was scanty and the testes were small and soft.

Laboratory on admission included: Hemoglobin of 10.3 g/D1,

MCV 88 fL, WBC 3.2, platelet count of 100,000; BUN of 8 mg/DL,

creatinine of 1.0 mg; bilirubin 2.9 total, normal alkaline phosphatase, AST of 120 a/L.

Patient 2.

After one hour of continuous tight substernal pain, a 53year-old white man, an accountant, is brought to the emergency room. He had been treated for hypertension for 10 years but did not adhere to his regimen nor did he see his physician regularly. Three years ago he was found to have adult-onset diabetes mellitus. He was treated with some success by diet alone but had difficulty losing weight. For the past year he has had recurrent episodes of tight substernal discomfort occurring two or three times per week. These were provoked by emotional stress or severe exertion and relieved in about 1 to 2 minutes by a sublingual nitroglycerin tablet or rest. He limited his activities to avoid these episodes. This pattern remained stable until a month ago when he observed his chest pain becoming more severe, more prolonged, and more easily provoked. He needed two or three nitroglycerin tablets for relief. One week prior to admission he was experiencing chest pain four to five times daily. The pain during the present attack was worse than usual, radiated to the neck and down the left arm, and was unrelieved by three nitroglycerin tablets. He felt ill and was nauseated and in a cold sweat, so he came to the hospital. Further questions reveal that the patient had decreased his activity and exposure to emotional tension over the past month. He has never smoked and has no other significant symptoms. The family history, however, is notable for a high frequency of coronary disease, hypertension, and diabetes.

The physical examination was normal except for the vital signs and heart: BP 160/95, P 83 with frequent premature beats, T 37.1° C, R 18. The lungs, jugular venous pressure, and carotid pulses were normal. The apical impulse was in the fourth and fifth left intercostal spaces just lateral to the midclavicular line and was about 5 cm in diameter. A prominent presystolic wave and a sustained outward systolic thrust were palpated. One auscultation, S1 was soft, S2 was normal, and there was a soft S3 and a loud S4. No murmurs were heard.

Patient 3.

A 73-year-old woman presented with progressive weakness and fatigue. Six months earlier, she had been admitted with melena and profound microcytic anemia. during that hospitalization, an extensive endoscopic (EGD, and colonoscopy) and radiographic gastrointestinal evaluation demonstrated only mild gastritis. She denied alcohol use and any medications other than sucralfate and an "iron pill." Previous surgeries (hysterectomy) and dental work had not been complicated by excessive bleeding. She believes that she had a melanotic stool 4 days ago, but has had normal bowel movements since.

Her temperature was 98° F, pulse 80 without orthostatic changes, respirations 16, BP 110/60. She had no petechiae, or purpura. Abdomen show no hepatosplenomegaly. The rectal exam was normal, and the stool guaiac was negative for occult blood.

Her hematocrit was 30% with a hemoglobin of 9.7 gm/DL and a normal white count and differential. The platelet count was 550, 000. The MCV was 78.

SHORT CASE QUESTIONS

ANSWER AT YOUR DESK

4. A 28-year-old man experienced the sudden onset of nausea, vomiting, and diarrhea after returning home from his girl friend's apartment. He was depressed because she told him to "never come back." He had consumed innumerable beers and a "jar of some kind of pills." The next morning he awoke with fever, chills, sweats, tinnitus, and visual hallucinations.

His temperature was 101.2° F, pulse 140, respirations 24, blood pressure 114/60. He was diaphoretic. Chest was clear with a hyperdynamic precordium. He had active bowel sounds, diffuse abdominal tenderness, no hepatosplenomegaly.

His ABG on room air: pH 7.45, P02 90 mm Hg, pC02 23 mm Hg, UA showed 4+ ketones. Na 148 mEq/L, K 5.4 mEq/L, C1 106 mEq/L, HC03 18 mEq/L. His AST was 220 IU/L, ALT 210 IU/L. Alcohol level was zero.

5. A 78-year-old man arrived in the emergency department after being found confused and incontinent of urine. According to his neighbor, the patient lived alone and seemed to be in good health.

His temperature was 96.4° F, pulse 90, respirations 22, blood pressure 130/78. He was confused with rambling, incoherent speech. The neurological exam was otherwise normal. His chest was clear and his cardiac exam revealed only a S4. The abdomen was normal, and the skin was normal.

His WBC was 2,600 with 62 % PMNs, 15 % bands. The Na was 146, K 4.9, Cl 106, and HC03 24. His glucose was 85, BUN 42. UA showed numerous WBCs and bacteria. His pH was 7.51, pC02 was 29 mm Hg, p02 was 64 mm Hg. CT of head: cerebral atrophy.

6. A 30-year-old man with slurred speech and unsteady gait was brought to the EC after a scuffle with police officers. He admitted to recent use of cocaine. He also complained of leg pains.

His temperature was 100.4° F; pulse 112; respirations 26; blood pressure 110/90. He was now awake and oriented. His chest was clear and the heart exam was normal. He had some increased tenderness to palpation of his leg muscles.

His CBC was normal. His UA showed: dark brown color, positive dipstick for blood, microscopic no WBCs, RBCs or bacteria. His Na was 138, K 5.9, C1 106, HC03 3, glucose 287 mg, BUN 14, creatinine 1.0, Ca 7.5, Mg 3.5, phosphate 7 mg/dl, AST 674 IU/L, ALT 278 IU/L, CPK 42,630 IU/L.

7. A 64-year-old woman presented with confusion, lethargy, and intermittent unresponsiveness. On physical exam she was lethargic, obese, and stuporous. Her blood pressure was 80/30 mm Hg and he pulse was 50 beats per minute and regular. She was afebrile. Her skin consistency was elastic. Her hair was coarse, short and greying. The eyebrows were thin. The lungs were clear to percussion. No cardiac murmurs or rubs were detected. Bowel sounds were normal. The rectal exam was normal. There was 2 + pitting edema over both lower extremities, but no clubbing or cyanosis were present. Cranial nerves II through XII, motor function, and sensory systems were normal. There were no pathologic reflexes, although the deep tendon reflexes were generally decreased in reactivity. The relaxation phase of the reflexes tended to be slowed.

8. A 45-year-old man comes to the emergency room with abdominal pain, nausea, occasional vomiting, which has persisted for 3 days. The pain is midepigastric and radiates to the back. He was hospitalized on two other occasions during the past 2 years for similar complaints and required nasogastric suction. He has a significant history of alcohol intake, but hasn't been drinking in the last 3 or 4 days. He appears acutely ill and is in moderate respiratory distress. His temperature is 100.9 F, the heart rate is 110/min and rhythm is regular, the blood pressure is 100/70. The abdomen is distended, has diffuse mild tenderness, some rigidity and guarding, hypoactive bowel sounds, and no abdominal scars. His CBC is normal, except for a WBC of 14,000. His urinanalysis is negative for glucose, protein, but is 1 + for ketones. His bilirubin is 4 mg/dL and his creatinine is 1.0, His BUN is 38, glucose is normal and his electrolytes are: Na 135, K 3.8, Chloride 92, and bicarbonate 20.

9. A 25-year-old occupational therapist saw a physician in the community clinic because of a rash on her leg which the physician diagnosed as erythema nodosum. She has no history of any recent illness, had no sickness in the past except for childhood diseases, and does not take oral contraceptives. Her physical examination is entirely unremarkable. She has no arthralgias, no lymphadenopathy, and no hepatomegaly or splenomegaly. Her chest film revealED bilateral hilar adenopathy and R paratracheal adenopathy.

10. A 14-year-old boy scout is lost in the desert of Big Bend National Park during a camping trip. He is found 3 days later wandering in the wilderness not having had anything to eat or drink, confused and almost delirious. His serum sodium concentration is 156 mEq/L.

11. In the evaluation of a patient with hypertension certain findings suggest the presence of a correctable secondary cause of the elevated blood pressure.

12. A patient receiving antibiotics post op after a complex cholecystectomy develops bleeding from her NG tube. Coagulation studies drawn show a PT of 17 seconds (prolonged) and a PTT of 55 seconds (also prolonged). Platelet count is normal. When questioned, the patient tells you that prior to her surgery she had had a prolonged period of decreased appetite and hadn't eaten well for a month. A review of the chart shows that she has been receiving antibiotics for about 10 days and nasogastric suction for longer. She has some purpura at her IV and venepuncture sites.

13. A 20-year-old woman, a student, is admitted to the hospital for evaluation of cramping abdominal pain and diarrhea of 2 months duration. She has been having 4-8 loose stools per day despite therapy with an anticholinergic drug, propantheline bromide prescribed 4 weeks prior to admission; she has also note rectal bleeding which has worsened during the past 2 weeks. Vital signs are temperature 101.5 F; pulse 96/min and blood pressure and respirations normal. There is minimal abdominal distention bilateral lower quadrant abdominal tenderness is present. Bowel sounds are slightly diminished. Rectal examination discloses no evidence of perirectal disease, but a stool specimen is strongly positive for occult blood.

14. A 40-year-old street person is found staggering and confused on a friday evening and is brought to the emergency room. On exam he is uncooperative, disheveled, and disoriented to person, place, and time. He says that he has been drinking everything in sight. Blood pressure is 140/70 with significant orthostatic drop. Pulse is 110 and regular, temperature is 99.8 and respirations are deep and 30 per

minute. The rest of the exam is normal except for a mildly tender abdomen without rebound. The neurologic exam is normal except for diminished touch in a stocking

distribution on the lower extremities.

Laboratory studies: CBC: Hct is 33 with MCV of 105, platelet count of 148,000 and WBC of 10,500. UA: patient was incontinent. Serum chemistry: Na 140, K 5.4, C1 102, C02 4, BUN 14, Creatinine 0.4, glucose 90. Arterial blood gases (room air): pH 7.1, pC02 28, P02 106. Serum osmolality 375.

SEE THE DISPLAYS FOR PHOTOGRAPHS, SLIDES ETC TO ANSWER THE FOLLOWING:

15. A 47-year-old woman with hypertension for five years presents with severe headache. She has been treated intermittently with numerous drugs, the most recent of which was clonidine and furosemide. She was told to discontinue the clonidine several days before because of postural hypotension and was begun on an ACE inhibitor. She awoke on the morning of admission with a severe headache; later in the day she had

diaphoresis, drowsiness, nausea, anxiety, and abdominal pain. There was no chest pain.

Blood pressure was 210/140 right arm supine, 210/138 left arm supine, 196/136 standing. She was drowsy, with some disorientation. There was no nuchal rigidity. A loud S4 was heard.

The CBC and electrolytes were normal; BUN 34 mg/dL, creatinine 1.2 mg/dL, UA showed 4+ proteinuria with a few RBCs/HPF, no casts or dysmorphic RBCs. EKG: LVH, nonspecific ST T changes. Chest radiograph: cardiomegaly. Her fundus is shown.

16. A 50-year-old woman presents with fatigue, weakness, and the onset of arthralgias. These have been accompanied by morning stiffness that lasts for up to one hour. The first joints affected were both wrists, her knuckles, and then her knees. Lately, she has experienced numbness in the thumb and index finger of her right hand. On exam she has tenderness in the MCP and PIP joints. There is decreased range of motion of both wrists and in the right hand there is thenar muscle atrophy.

Pictures of her hands are shown.

17. After a routine insurance examination, a 36-year-old man was told that there was something wrong with his ECG and he should consult his doctor. A repeat ECG shows a left ventricular hypertrophy pattern. The patient has never had chest pain, never had a heart attack, and has no history of diabetes or hypertension. He has no dyspnea on exertion, sleeps flat, and has no night cough. He is tall and lanky. The blood pressure is 130/30 in both arms. Ophthalmoscopy shows no evidence of present or past hypertension. He has pectus excavatum. The apex beat is diffusely felt between the left midclavicular line and the anterior axillary line in the fifth and sixth intercostal spaces. A slight left ventricular heave is also noted. But there are no basal rales, neck veins are not distended. On applying the diaphragm of the stethoscope firmly to the chest in the area of the third left intercostal space--with the patient sitting up, learning forward, and in expiration--you hear a grade 2/4 soft, high-pitched, decrescendo murmur starting with S2. A photograph of his hands is shown.

18. A 68-year-old man presents with tachycardia, and complains of more than usual fatigue during jogging. In the EC the EKG on display was obtained.

19. A 55-year-old insurance salesman experiences sudden onset of chest pain. His EC EKG is shown.

20. A 70-year-old woman with weakness and fatigue presents to the emergency center. She is pale and has diminished proprioception on physical exam. Her hematocrit is 15% and her MCV is 125. Her reticulocyte count is 4.0 %. The peripheral blood film is on a microscope.

21. A 65-year-old woman presents with fatigue, and the recent onset of severe constipation. Exam shows a brown guaiac + stool. Her hematocrit is 30 % with a MCV of 75 fL. The platelet count is 600,000. A peripheral blood film is on a microscope.

22. A 45-year-old woman with a history of sudden onset of cough, rusty tinged sputum, and RT sided pleuritic chest pain. She has fever of 101° F on admission. Chest X-ray and gram stain of sputum are available.

23. A 20-year-old woman presents with a history of chest pain. The chest pain is relieved when she sits up and leans forward. She has a history of arthralgias, patchy hair loss, photosensitivity and a facial rash apparent on her cheeks. A chest x-ray is shown.

24. A 70-year-old woman presents with shortness of breath at night, dyspnea on exertion, and lower extremity edema. These symptoms have gradually worsened over 3 weeks. A chest film is shown.