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Dr. Zahoor
1
A 26 year old woman presents to the ER
complaining of sudden onset of palpitations
and severe shortness of breath and coughing.
She reports that she 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 and alcohol.
2
On examination, her heart rate is between
110 and 150 bpm and is irregularly irregular,
with blood pressure of 92/65mmHg, respiratory
rate of 24 breaths per minute and oxygen
saturated of 94% on room air. She appears
uncomfortable with laboured respirations. She is
coughing, producing scanty amounts of frothy
sputum with pinkish tint. She has ruddy cheeks
and a normal jugular venous pressure. She has
bilateral inspiratory crackles in the lower lung
fields.
3
On cardiac examination, her heart
rhythm is irregularly irregular with a loud S1,
and low pitched 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:
4
1.
What is the most likely diagnosis?
2.
What is your next step?
5
1.
2.
Atrial fibrillation caused by mitral stenosis
Cardiac rate control with intravenous beta
blockers
6
7
A 42 year old woman presents to the ED
complaining of 24 hours of severe, steady
epigastric abdominal pain, radiating to her back,
with several episodes of nausea and vomiting.
She has experienced similar painful episodes in
the past, usually in the evening following heavy
meals, but the episodes always resolved
spontaneously within an hour or two. This time
the pain did not improve, so she sought medical
attention. She has no medical history and takes
no medications. She is married, has three
children, and does not drink alcohol or smoke.
8
On examination, she is afebrile, tachycardiac
with a heart rate of 104 bpm, blood pressure
115/74mmHg, and shallow respirations of 22
breaths per minute. She is moving uncomfortably
on the stretcher, her skin is warm and she has
scleral icterus. Her abdomen is soft, mildly
distended with marked right upper quadrant and
epigastric tenderness to palpation, hypoactive
bowel sounds, and no masses or organomegaly
appreciated. Her stool is negative for occult
blood.
9
Laboratory studies are significant for a total
bilirubin (9.2mg/dL) with a direct fraction of
4.8mg/dL.
Alkaline phosphatase 285 IU/L (N: 39 – 117)
Aspartate aminotransferase (AST) 78 IU/L (N: 12-40)
Alanine aminotransferase (ALT) 92 IU/L (N: < 40)
Amylase level 1249 IU/L (N: 25-125)
Her leukocyte count is 16,500/mm3 with 82%
polymorphonuclear cells and 16% lymphocytes.
A plain film of the abdomen shows a non specific gas
pattern and no pneumoperitoneum.
10
1.
What is the most likely diagnosis?
2.
What is the most likely underlying etiology?
3.
What is your next diagnostic step?
11
1.
2.
3.
Acute pancreatitis
Choledocholithiasis (common bile duct
stone)
Right upper quadrant abdominal
ultrasonography
12
13
A 58 year old man comes to see you
because of shortness of breath. He has
experienced mild dyspnea on exertion for a
few years, but more recently he has noted
worsening shortness of breath with minimal
exercise and the onset of dyspnea at rest. He
has difficulty reclining and as a result, he
spends the night sitting up in a chair trying to
sleep. He reports a cough with production of
yellowish brown sputum every morning
throughout the year.
14
He denies chest pain, fever, chills, or
lower extremity edema. He has smoked about
two packs of cigarettes per day since age 15
years. He does not drink alcohol. A few
month ago, the patient went to clinic for
evaluation of his symptoms, and received a
prescription for some inhalers, the names of
which he does not remember. He was also
told to find a primary care physician for
further evaluation.
15
On physical examination, his blood
pressure is 135/85mmHg, heart rate 96bpm,
respiratory rate 28 breaths per minute and
temperature 97.6oF. He is sitting in a chair,
leaning forward, with his arms braced on his
knees. He appears uncomfortable with
laboured respirations and cyanotic lips. He is
using accessory muscles of respiration and
chest examination reveals wheezes and
Ronchi bilaterally, but no crackles are noted.
16
The anteroposterior diameter of the chest
wall appears increased, and he has inward
movement of the lower rib cage with
inspiration. Cardiovascular examination
reveals distant heart sounds but with a
regular rate and rhythm, and his jugular
venous pressure is normal. His extremities
show no cyanosis, edema, or clubbing.
17
1.
What is the most likely diagnosis?
2.
What is the next best diagnostic test?
3.
What is the best initial treatment?
18
1.
2.
3.
Chronic Obstructive pulmonary disease
(COPD) with acute exacerbation
Arterial blood gas to assess oxygenation and
acid base status
Oxygen by nasal cannula, followed closely by
bronchodilators and steroids for
inflammatory component
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