Case 8

 This case highlights the importance of using 2 views in patients with trauma.

Case 7

A 54 year old female with past medical history of pulmonary hypertension, fibromyalgia, chronic obstructive pulmonary disease, coronary artery disease and hypertension presented to the emergency department with complaints of increased dyspnea, lower extremity edema, weight gain, orthopnea, fevers, chills, night sweats over the past few months. She denied any cough or sputum production. The patient was on trepostinil (remodulin) infusion since 3 years. She had a history of line infection two years ago which was successfully treated with antibiotics. Patient had a right subclavian port placed about ten months ago. Her other medications included estrogen, escitalopram, warfarin and gabapentin. The patient did have a remote history of smoking although she had quit smoking eight years prior. She denied any drug allergies, alcohol or intravenous drug abuse.

On presentation her vitals were found to be a blood pressure of 160/90, heart rate 88, temperature 36.9, and oxygen saturation 93% on 2 liters by nasal canula. The review of systems was essentially negative except for the history of present illness. Her examination was positive for tachypnea, a 3/6 systolic murmur, 2+ bilateral lower extremity pedal edema. Rest of the examination was normal.

Blood cultures were drawn in the emergency department. Initial lab evaluation showed WBC count 8700 / mm3, neutrophils 83%, lymphocytes 13% and hemoglobin 13.3 g/dl. Electrolytes, BUN and creatinine were normal.

Patient underwent transthoracic echocardiogram which showed a small mobile mass (vegetation) on the aortic side of the aortic valve (Figure 1) and another round mass in the right ventricle attached to chordae or the moderator band measuring 1.2 cm in diameter.

The blood cultures grew plump gram negative coccoid rods (Figure 2) on day 3. The blood culture isolate grew pale-pink shiny raised and mucoid colonies on 5% sheep blood agar plates (Figures 3, 4 and 5). The biochemical results (Figure: 6) were as follows (Table 1):

Case 6

A 25-year-old woman presented to her primary care physician for evaluation of abdominal pain. Her discomfort had begun 6 months earlier and was localized to the right upper quadrant of the abdomen. She described a constant pressure unrelated to food intake that was associated with intermittent nausea and vomiting. She reported no change in urine or stools and no hematochezia, melena, dysphagia, anorexia, increase in abdominal girth, early satiety, or change in weight. She also had no lethargy, fatigue, pruritus, jaundice, night sweats, fever, easy bruising, or bleeding.

The patient's medical history was notable for type 1 diabetes mellitus, which had been diagnosed in childhood and was complicated by several episodes of diabetic ketoacidosis, hypothyroidism, psoriasis, and a seizure disorder, as well as juvenile rheumatoid arthritis, which was diagnosed when she was 18 months of age, after the development of arthritis in her right ankle and uveitis in both eyes. Her growth was normal despite eventual involvement of arthritis in both ankles and knees. She had been treated with naproxen, methotrexate, and glucocorticoids. Her current medications included carbamazepine, methotrexate, levothyroxine, and insulin. Her cumulative dose of methotrexate was 1.3 g. She reported no use of over-the-counter medications or herbal supplements. She worked as a nurse, was unmarried, and had no children. She smoked seven cigarettes a day and had done so for 10 years. She said she did not use alcohol or illicit drugs and had no history of blood transfusions, no occupational exposure to blood, and no tattoos. She was not sexually active and had no history of sexually transmitted infections. There was no family history of diabetes, arthritis, autoimmune diseases, or liver disease.
What whould you do next, and what is your differential diagnosis

Case 5

A 25-year-old primigravid woman at
42 weeks' gestation delivers a 4000-g (8-lb
13-oz) newborn after induction of labor with
oxytocin. The first and second stages of labor
lasted 14 and 3 hours, respectively. A midline
episiotomy was done, and the placenta
appeared to be intact. Ten minutes after
delivery, she has copious vaginal bleeding
estimated to be 500 mL over a 5-minute
period; the fundus is soft and boggy. Which of
the following is the most likely cause of the
hemorrhage?
(A) Cervical laceration
(B) Disseminated intravascular
coagulation
(C) Retained placental tissue
(D) Uterine atony
(E) Uterine inversion

Case 4

A 15-year-old girl is brought to the physician
because of irritability, restlessness, difficulty
concentrating, and deteriorating academic
performance over the past 2 months. She has
had occasional heart palpitations and a 1-kg
(2-lb) weight loss during this period despite an
increased appetite. Menarche was at the age of
12 years, and her menses occur at regular
intervals. She does not use drugs and is not
sexually active. Her parents state that she has
no problems at home. Examination shows no
abnormalities. Serum triiodothyronine (T3)
and thyroxine (T4) concentrations are
increased. Which of the following is the most
likely diagnosis?
(A) Attention-deficit/hyperactivity
disorder
(B) Diabetes mellitus
(C) Hyperthyroidism
(D) Pituitary adenoma
(E) Thyroid cancer

Case 3

A 17-year-old boy comes to the physician
because of right groin pain for 2 hours;
elevation of the scrotum does not relieve the
pain. There is no history of trauma. He is
sexually active and has had multiple sexual
partners over the past 3 years. He does not use
condoms regularly. He had chlamydial
urethritis 1 year ago treated with doxycycline.
Examination shows an enlarged, swollen,
erythematous, and acutely tender right
scrotum. The left testis is found in a horizontal
position; the cremasteric reflex is absent on the
right. Which of the following is the most likely
diagnosis?
(A) Epididymitis
(B) Hemorrhagic tumor
(C) Incarcerated hernia
(D) Torsion of the testicle
(E) Torsion of the testicular appendix