Case Series Internal Med

Dr. Okon, MRCS

● While seeing patients in your preceptor’s clinic, you have the opportunity
to meet and examine one of her long-time patients, a 52-year-old woman
who presents for her yearly physical examination. She has been fine and
has no complaints today.
● Her medical history is notable only for borderline hypertension and
moderate obesity. Last year her fasting lipid profile was acceptable for
someone without known risk factors for coronary artery disease. Her
mother and older brother have diabetes and hypertension. At prior visits,
you see that your preceptor has counseled her on a low-calorie, low-fat
diet and recommended that she start an exercise program. However, the
patient says she has not made any of these recommended changes.
With her full-time job and three children, she finds it difficult to exercise,
and she admits that her family eats out frequently.
● Today her blood pressure is 140/92 mm Hg. Her body
mass index (BMI) is 29 kg/m2. Her examination is
notable for acanthosis nigricans at the neck but
otherwise is normal. A Papanicolaou (Pap) smear is
performed, and a mammogram is offered. The patient
has not eaten yet today, so on your preceptor’s
recommendation, a fasting plasma glucose test is
performed, and the result is 140 mg/dL.
● What is your diagnosis?
● What is your next step?
● A patient comes in for a fasting plasma glucose test. On
two separate occasions, the result has been 115 mg/dL
and 120 mg/dL. Which of the following is the most
appropriate next step?
● A. Reassurance that these are normal blood sugars.
● B. Recommend weight loss, an ADA diet, and exercise.
● C. Diagnose diabetes mellitus and start on a sulfonylurea.
● D. Recommend cardiac stress testing.
● E. Obtain stat arterial blood gas and serum ketone levels.
● A 58-year-old woman comes to the office after a near-
fainting spell she experienced 1 day ago. She was outside
playing tennis when she vomited and felt lightheaded.
● She spent the rest of the day lying down with mild, diffuse,
abdominal pain and nausea. She had no fever or diarrhea.
She reports several months of worsening fatigue; mild,
intermittent, generalized abdominal pain; and loss of
appetite with a 10- to 15-lb unintentional weight loss. Her
medical history is significant for hypothyroidism for which
she takes levothyroxine. She takes no medications.
●
● On examination, her temperature is 99.8°F, heart rate 102 bpm, blood
pressure 89/62 mm Hg, and normal respiratory rate. She does
become lightheaded, and her heart rate rises to 125 bpm upon
standing with a drop in systolic blood pressure to 70 mm Hg. She is
alert and well tanned, with hyperpigmented creases in her hands. Her
chest is clear, and her heart rhythm is tachycardic but regular. On
abdominal examination, she has normal bowel sounds and mild
diffuse tenderness without guarding. Her pulses are rapid and
thready. She has no peripheral edema. Initial laboratory studies are
significant for Na 121 mEq/L, K 5.8 mEq/L, HCO3 16 mEq/L, glucose
52 mg/dL, and creatinine 1.0 mg/dL.
● What is the most likely diagnosis?
● What is your next step?
●
● A 37-year-old previously healthy woman presents to
your clinic for unintentional weight loss. Over the past
3 months, she has lost approximately 15 lb without
changing her diet or activity level. Otherwise, she
feels great. She has an excellent appetite, no
gastrointestinal complaints except for occasional
loose stools, a good energy level, and no complaints
of fatigue. She denies heat or cold intolerance. On
examination, her heart rate is 108 bpm, blood
pressure 142/82 mm Hg, and she is afebrile.
● When she looks at you, she seems to stare, and
her eyes are somewhat protuberant. You note a
large, smooth, nontender thyroid gland and a 2/6
systolic ejection murmur on cardiac examination,
and her skin is warm and dry. There is a fine
resting tremor.
● What is the most likely diagnosis?
● How could you confirm the diagnosis?
● What are the options for treatment?
● An 18-year-old woman is brought to the emergency room by her
mother because the daughter seems confused and is behaving
strangely. The mother reports the patient has always been
healthy and has no significant medical history, but she has lost
20 lb recently without trying and has been complaining of fatigue
for 2 or 3 weeks.
● The patient had attributed the fatigue to sleep disturbance, as
recently she has been getting up several times at night to
urinate. This morning, the mother found the patient in her room,
complaining of abdominal pain, and she had vomited.
● She appeared confused and did not know that today was a
school day.
● On examination, the patient is slender, lying on a stretcher
with eyes closed, but she is responsive to questions. She is
afebrile, and has a heart rate 118 bpm, blood pressure
125/84 mm Hg, with deep and rapid respirations at the rate of
24 breaths per minute. Upon standing, her heart rate rises to
145 bpm, and her blood pressure falls to 110/80 mm Hg. Her
funduscopic examination is normal, her oral mucosa is dry,
and her neck veins are flat. Her chest is clear to auscultation,
and her heart is tachycardic with a regular rhythm and no
murmur. Her abdomen is soft with active bowel sounds and
mild diffuse tenderness, but no guarding or rebound. Her
neurologic examination reveals no focal deficits.
● Laboratory studies include serum Na 131 mEq/L, K 5.3
mEq/L, Cl 95 mEq/L, CO2 9 mEq/L, blood urea nitrogen
(BUN) 35 mg/dL, creatinine 1.3 mg/dL, and glucose 475
mg/dL. Arterial blood gas reveals pH 7.12 with PCO2 24
mm Hg and PO2 95 mm Hg. Urine drug screen and urine
pregnancy test are negative, and urinalysis shows no
hematuria or pyuria, but 3+ glucose and 3+ ketones. Chest
radiograph is read as normal, and plain film of the abdomen
has nonspecific gas pattern but no signs of obstruction.
● What is the most likely diagnosis?
● What is your next step?
● A 56-year-old man comes to the ER complaining of chest discomfort.
He describes the discomfort as a severe, retrosternal pressure
sensation that had awakened him from sleep 3 hours earlier. He
previously had been well but has a medical history of
hypercholesterolemia and a 40-pack-year history of smoking.
● On examination, he appears uncomfortable and diaphoretic, with a
heart rate of 116 bpm, blood pressure of 166/102 mm Hg, respiratory
rate of 22 breaths per minute, and oxygen saturation of 96% on room
air. Jugular venous pressure appears normal.
● Auscultation of the chest reveals clear lung fields, a regular rhythm
with an S4 gallop, and no murmurs or rubs. A chest radiograph shows
clear lungs and a normal cardiac silhouette. The electrocardiogram
(ECG) is shown below
● A 26-year-old woman originally from Nigeria presents
to the ER complaining of sudden onset of palpitations
and severe shortness of breath and coughing. She
reports that she has experienced several episodes of
palpitations in the past, often lasting a day or two, but
never with dyspnea like this. She has a history of
rheumatic fever at the age of 14 years. She is now 20
weeks pregnant with her first child and takes prenatal
vitamins. She denies use of any other medications,
tobacco, alcohol, or illicit drugs.
● On examination, her heart rate is between 110 and 130 bpm and
is irregularly irregular, with blood pressure of 92/65 mm Hg,
respiratory rate of 24 breaths per minute, and oxygen saturation
of 94% on room air. She appears uncomfortable, with labored
respirations. She is coughing, producing scant amounts of frothy
sputum with a pinkish tint. She has ruddy cheeks and a normal
jugular venous pressure. She has bilateral inspiratory crackles in
the lower lung fields. On cardiac examination, her heart rhythm is
irregularly irregular with a loud S1 and lowpitched diastolic
murmur at the apex. Her apical impulse is nondisplaced. Her
uterine fundus is palpable at the umbilicus, and she has no
peripheral edema. An ECG is obtained
● What is the most likely diagnosis?
● What is your next step?
●
● A 65-year-old white woman is brought to the ER by her family for
increasing confusion and lethargy over the past week. She was
recently diagnosed with limited stage small cell lung cancer but has
not begun cancer treatment. She has not been febrile or had any
other recent illnesses. She is not taking any medications.
● Her blood pressure is 136/82 mm Hg, heart rate is 84 bpm, and
respiratory rate is 14 breaths per minute and unlabored. She is
afebrile. On examination, she is an elderly appearing woman who is
difficult to arouse and reacts only to painful stimuli. She is able to
move her extremities without apparent motor deficits, and her deep
tendon reflexes are decreased symmetrically. The remainder of her
examination is normal, with a normal jugular venous pressure and
no extremity edema.
● You order some laboratory tests, which reveal the
serum sodium level is 108 mmol/L, potassium 3.8
mmol/L, bicarbonate 24 mEq/L, blood urea nitrogen
(BUN) 5 mg/dL, and creatinine 0.5 mg/dL. Serum
osmolality is 220 mOsm/kg,and urine osmolality is 400
mOsm/kg. A computed tomographic (CT) scan of the
brain shows no masses or hydrocephalus.
● What is the most likely diagnosis?
● What is your next step in therapy?
● What are the complications of therapy?