A 75-year-old woman presents with a chief complaint of cough while eating

 A 75-year-old woman with a history of diabetes mellitus, hypertension, hyperlipidemia, and peripheral artery disease presents with a chief complaint of cough while eating. On further history, she describes trouble initiating her swallow as well as recent dysarthria.

Which of the following is the most likely cause of her symptoms?

A. Achalasia

B. Esophageal web

C. Stroke

D. Zenker diverticulum

Answer:

A 75-year-old woman with a 50-pack-year history of cigarette smoking presents to her primary care physician (PCP) with 10 years of progressive dyspnea on exertion

 

A 75-year-old woman with a 50-pack-year history of cigarette smoking presents to her primary care physician (PCP) with 10 years of progressive dyspnea on exertion. She notes episodic wheezing and experiences a “chest cold” about two times per year. Her examination reveals distant breath sounds to auscultation and hyper-resonant chest to percussion, with otherwise unremarkable examination. A CXR demonstrates hyperinflation with flattening of the bilateral hemidiaphragms. Pulmonary function tests (PFTs) reveal a forced expiratory volume (FEV1) of 50% predicted, forced vital capacity (FVC) of 70% predicted, and FEV1/FVC of 0.50. There is no response to bronchodilator.

What pattern best describes her PFT results?

A. Cannot determine without more information

B. Normal

C. Obstructive

D. Restrictive

Answer:

A 75-year-old man with a history of hypertension and peptic ulcer disease presents with dyspnea on exertion

 A 75-year-old man with a history of hypertension and peptic ulcer disease presents with dyspnea on exertion to the emergency department (ED). He notes black-colored stools for the past 2 weeks. His initial examination is notable for conjunctival pallor, clear lung fields without rales, wheezing, or rhonchi, as well as tachycardia with a regular rhythm, normal s1 and s2, and without murmurs, rubs, or gallops. Initial laboratory workup reveals a hemoglobin of 5.5 g/dL, reduced from a baseline of 12 g/dL on routine outpatient laboratory testing from 3 months prior. His basic metabolic panel, arterial blood gas (ABG), and lactateare all within normal limits. A chest radiograph (CXR) is normal.

What is the mechanism of this man’s dyspnea on exertion?

A. Decreased cardiac output

B. Decreased oxygen delivery

C. Decreased systemic vascular resistance

D. High-output heart failure

E. Pulmonary edema

Answer:

A 59-year-old man with a history of hypertension and hyperlipidemia presents with 1 hour of substernal chest pressure

 A 59-year-old man with a history of hypertension and hyperlipidemia presents with 1 hour of substernal chest pressure rated an 8 on a scale of 1 to 10 with radiation down the left arm and associated with diaphoresis. Initial vital signs are notable for a blood pressure (BP) of 92/64 mmHg and a heart rate (HR) of 92 beats/min. His electrocardiogram (ECG) is shown below

What is the most likely diagnosis?

A. Anterior ST-elevation myocardial infarction

B. Inferior ST-elevation myocardial infarction

C. Pericarditis

D. ST changes not meeting specific ischemia criteria; additional ECGs should be obtained.

ANSWER: 

A 13 year old girl with history of lethargy, joint pain and cough....

A 13 years old girl presented to accident and emergency department with a history of lethargy, joint pain and cough. Both of her parents are from Jamaica. Her problem started one month ago with an upper respiratory infection. She was seen by her family doctor and diagnosed to have a viral infection. She has a past history of skin rashes that was never seen by her family doctor.
On examination she has a palpable cervical lymph nodes of various sizes, a congested throat, generalized myalgia and a swollen ankle joint on the left side.
Her BP is 120/75 mmHg, HR 90 bmp, RR 22/min.
A urine test shows protein+ve with red cells.
other tests are as follows:
Hb = 9.7 g/dl
TLC = 4x10-9/l with neutrophils and lymphopenia.
Platelets =100x10-9/l
Retic count = 2.6%
CRP = 20

Questions:
1. Which three other investigations should be carried out?
2. What treatments should you prescribe?
3. What are three possible differential diagnosis?

Answers:

Anorexia And Fever - Case Study

A 22-year-old man presented with malaise and anorexia for 1 week. He vomited on one occasion, with no blood. He has felt feverish but has not taken his temperature. For 2 weeks he has had aching pains in the knees, elbows and wrists without any obvious swelling of the joints.
He has not noticed any change in his urine or bowels.
Five years ago he had glandular fever confirmed serologically. He smokes 25 cigarettes per day and drinks 20–40 units of alcohol per week. He has taken marijuana and ecstasy occasionally over the past 2 years and various tablets and mixtures at clubs without being sure of the constituents. He denies any intravenous drug use. He has had irregular homosexual contacts but says that he has always used protection. He claims to have had an HIV test that was negative 6 months earlier. He has not traveled abroad in the last 2 years.
He is unemployed and lives in a flat with three other people. There is no relevant family history.

Examination
He has a temperature of 38.6°C and looks unwell. He looks as if he may be a little jaundiced. He is a little tender in the right upper quadrant of the abdomen. There are no abnormalities to find on examination of the joints or in any other system.

Investigations
(normal values shown in brackets)
Haemoglobin 14.1 g/dL (13.3–17.7 g/dL)
Mean corpuscular volume (MCV) 85 fL (80–99 fL)
White cell count 11.5 × 109/L (3.9–10.6 × 109/L)
Platelets 286 × 109/L (150–440 × 109/L)
Prothrombin time 17 s (10–14 s)
Sodium 135 mmol/L (135–145 mmol/L)
Potassium 3.5 mmol/L (3.5–5.0 mmol/L)
Urea 3.2 mmol/L (2.5–6.7 mmol/L)
Creatinine 64 μmol/L (70–120 μmol/L)
Bilirubin 50 mmol/L (3–17 mmol/L)
Alkaline phosphatase 376 IU/L (30–300 IU/L)
Alanine aminotransferase 570 IU/L (5–35 IU/L)
Fasting glucose 4.1 mmol/L (4.0–6.0 mmol/L)

Questions
• What is your interpretation of the findings?
• What is the likely diagnosis?
• What treatment is required?

Answers And Discussion