Residents' Clinics
69-Year-Old Woman With Dyspnea and Cough Productive of White Sputum
A 69-year-old woman was admitted to our institution with progressive dyspnea and cough productive of white sputum. Three months earlier, the patient was hospitalized elsewhere for evaluation of fever, headache, and fatigue. Results of a right temporal artery biopsy were consistent with giant cell arteritis (GCA). She was treated with prednisone (50 mg/d) and initially improved, but after 6 weeks of therapy, she again experienced feelings of malaise. Her erythrocyte sedimentation rate (ESR) remained elevated at 75 mm/h.80-Year-Old Man With Massive Leg Swelling
An 80-year-old man was admitted to the hospital with a 2-month history of painful swelling of his right lower extremity. His medical history was remarkable for metastatic prostate cancer, radical prostatectomy, androgen deprivation therapy with goserelin acetate (a gonadotropin-releasing hormone analogue used to treat prostate cancer, breast cancer, and endometriosis), and radiation therapy for cancer recurrence with bony metastases. He had no history of claudication. The patient had undergone right total hip arthroplasty 6 months previously and lower back surgery 3 months later.73-Year-Old Man With Increasing Abdominal Girth and Dyspnea
A 73-year-old man with a history of type 2 diabetes mellitus, hyperlipidemia, and obesity presented to the emergency department with a 3-month history of increasing abdominal girth and shortness of breath. He also noted some mild abdominal discomfort when he moved. He denied nausea, vomiting, diarrhea, constipation, chest pain, fevers, and significant alcohol use. His medications included amlodipine, aspirin, glyburide, and hydrochlorothiazide.65-Year-Old Woman With Shortness of Breath and Dark Urine
A 65-year-old previously healthy woman presented to her primary care physician with a 6-week history of increasing dyspnea, accompanied by a dry cough, fatigue, malaise, and poor appetite. Before her initial presentation and the onset of the aforementioned symptoms, she had attributed her illness to an upper respiratory tract infection. She also reported a 1-week history of passing dark urine and had been treated empirically 2 weeks previously with a 3-day course of oral trimethoprim-sulfamethoxazole for presumptive urinary tract infection.35-Year-Old Woman With Recurrent Palpitations
A 35-year-old woman presented to the outpatient clinic with a 2-week history of episodic palpitations. She noted that each episode was abrupt in onset and would last approximately 1 to 2 hours before abating gradually. She denied chest pain, shortness of breath, and light-headedness and had no history of similar symptoms.33-Year-Old Man With Syncope
A 33-year-old man presented for evaluation of syncope. A few weeks earlier, he had become light-headed and developed mild chest discomfort and visual changes while running from home plate to first base during a softball game. A few days before evaluation, he had been running on his treadmill when he became light-headed, lost consciousness, fell, injured his nose, and broke his glasses. Bystanders observed no seizure-like activity. He experienced no bowel or bladder incontinence, tongue biting, or postevent confusion.26-Year-Old Man With Recurrent Urinary Tract Infections
A 26-year-old male college student presented with 1 week of constant, right lower quadrant, throbbing abdominal pain that was worse after eating and accompanied by bilious emesis. He had experienced similar, albeit less severe and self-limited, episodes of abdominal pain during the preceding 6 months. He denied fevers or chills but had lost 4.5 kg (10 lbs) in the past 6 months. During the same time period, he was treated twice with antibiotics for urinary tract infections (UTIs) after reporting symptoms of dysuria and noting “bubbles” in his urine.78-Year-Old Man With Nausea and Chest Pain
A 78-year-old man presented with a constant, substernal, sharp, nonradiating chest pain of 6 hours' duration; he rated the pain's severity as 5 on a 10-point scale. He denied previous chest discomfort. His chest pain was preceded by 1 day of epigastric abdominal pain and episodes of nausea and nonbloody emesis. He described the epigastric pain as constant, sharp, and band-like, noting that it was exacerbated by food. Findings were otherwise unremarkable on a complete review of systems. Before this illness, he had exercised daily by jogging on a treadmill.85-Year-Old Man With Epistaxis
An 85-year-old man with a medical history notable for monoclonal gammopathy of undetermined significance (MGUS), prostate cancer, bladder cancer, and squamous cell skin cancer presented to the emergency department with periodic epistaxis of 3 to 4 weeks' duration. The bleeding was spontaneous without antecedent trauma. The episodes of epistaxis usually lasted for about an hour. Pressure to the nares would stop the bleeding. The patient noted prolonged bleeding of his gums after brushing his teeth.51-Year-Old Hospitalized Man With a Painful Leg
A 51-year-old Somali man was admitted to an inpatient cardiology service at Saint Marys Hospital, a Mayo Clinic–affiliated hospital in Rochester, MN, with symptoms of fever and progressively worsening shortness of breath. Chest radiography demonstrated substantial pulmonary edema secondary to volume overload in the setting of acute worsening of chronic renal failure. Initial laboratory investigation yielded the following notable results (reference ranges provided parenthetically): leukocyte count, 30.3 × 109/L (3.5-10.5 × 109/L); blood urea nitrogen, 142 mg/dL (8-24 mg/dL); and creatinine, 12.6 mg/dL (0.9-1.4 mg/dL).62-Year-Old Woman With Fever, Dyspnea, Pleuritic Chest Pain, and Weight Loss
A 62-year-old woman with rheumatoid arthritis (RA) presented for evaluation of chronic pleuritic chest pain, dyspnea, cough, odynophagia, fatigue, weight loss of 16.6 kg (30 lb), and migratory joint pains. Ten years earlier, RA had been diagnosed on the basis of polyarticular inflammatory arthritis. Rheumatoid factor (RF) had subsequently been positive and anticyclic citrullinated peptide (anti-CCP) antibodies negative. No signs or symptoms of underlying connective tissue disease (CTD) had been reported, and no serologic testing for CTD performed.37-Year-Old Woman With Palpitations and Fatigue
A 37-year-old woman presented to the emergency department with palpitations, fatigue, and exertional dyspnea of 2 months' duration. The palpitations were persistent at rest and were not associated with anxiety. Review of the patient's medical history revealed that a prior pregnancy was complicated by postpartum cardiomyopathy. She was afebrile, had tachycardia (120 beats/min), and had a normal blood pressure of 118/64 mm Hg. Findings on physical examination were unremarkable, apart from trace bilateral lower extremity edema.44-Year-Old Man With Shortness of Breath, Fatigue, and Paresthesia
A 44-year-old man presented to the Primary Care Internal Medicine clinic with a 1-month history of shortness of breath, fatigue, and paresthesia. He reported increasing shortness of breath while stocking shelves at work and recently stopped recreational jogging because of this symptom. He also described a new, painless numbness and tingling in his fingertips bilaterally.51-Year-Old Man With Heart Murmur
A 51-year-old man presented to the internal medicine clinic for a Department of Transportation medical examination to renew his commercial motor vehicle license. He denied any symptoms at the time of his visit. On detailed questioning, however, the patient reported progressive dyspnea on exertion of several months' duration. These symptoms were not particularly worrisome to the patient because he attributed them to deconditioning.74-Year-Old Woman With New-Onset Myoclonus
A 74-year-old female nursing home resident with Alzheimer disease was admitted to the hospital with a 5-month history of aggressive behavior, including physically striking other nursing home residents. She had been treated with quetiapine with mild improvement; however, she became tremulous while receiving this medication and so was switched to 0.125 mg/d of risperidone orally. Unfortunately, the patient continued to act aggressively and was brought to the emergency department, where she was unable to follow commands or answer questions appropriately.82-Year-Old Man With Bilateral Leg Swelling
An 82-year-old man with a medical history remarkable for chronic heart failure, diabetes mellitus, benign prostatic hyperplasia (BPH), and degenerative joint disease presented to the outpatient clinic with bilateral lower extremity swelling of 1 month's duration. The lower extremity edema was bilateral but slightly worse on the right. The edema worsened during the day but transiently improved when the patient was in the supine position. He had no symptoms of paroxysmal nocturnal dyspnea, angina, or orthopnea.52-Year-Old Woman With Dysphagia
A 52-year-old woman presented with dysphagia, which started when she was 30 years old. Initially, the dysphagia was intermittent but had progressed to daily occurrences during the past 2 years. She had progessively more difficulty in swallowing solids, but not liquids. The patient described a spasmlike sensation in her chest, which occurred as soon as she started eating; this had become more prominent during the past 6 months. Almost once a week, food would “get stuck” in her esophagus, and she had to regurgitate it to relieve the discomfort.38-Year-Old Woman With Hypertension, Headaches, and Abdominal Bruit
A 38-year-old woman presented to her local clinic for recurrent episodes of headache of several weeks' duration. Evaluation revealed a blood pressure of 202/136 mm Hg. The patient was prescribed 37.5 mg of triamterene with 25 mg of hydrochlorothiazide (1 tablet) twice daily and 50 mg of atenolol once daily.52-Year-Old Man With Arthralgias, Fever, and Fatigue
A 52-year-old previously healthy man was admitted to an inpatient internal medicine resident hospital service with a 2-week history of profound generalized fatigue, nocturnal fevers (temperature as high as 39.4°C [103°F]), cold sweats, anorexia, and bilateral hand swelling and numbness. The swelling progressed to symmetrically involve his elbows, shoulders, knees, and ankles. He also reported arthralgias and profound weakness that had caused him to be confined to a wheelchair. He experienced joint stiffness of less than 30 minutes' duration in the morning that improved with activity.68-Year-Old Woman With Chronic Cough and Recurrent Pleural Effusions
A 68-year-old woman with a history of hypertension, paroxysmal atrial fibrillation, and liver transplant for primary sclerosing cholangitis (PSC) presented with a 2-month history of cough and shortness of breath. Her cough, which had gradually worsened, progressed to dyspnea after several feet of walking. She denied fever, chills, sick contacts, chest pain, palpitations, orthopnea, and paroxysmal nocturnal dyspnea. She had taken levofloxacin for a presumed upper respiratory tract infection with no relief and was receiving oral immunosuppressive therapy with 1 mg/d of prednisone and 25 mg of cyclosporine twice daily.77-Year-Old Woman With Back Pain and Shortness of Breath
A 77-year-old woman presented to the emergency department with back pain, which began shortly after moving furniture 1 week before presentation. The pain was persistent, did not radiate, limited activities of daily living, and was unrelieved by conservative measures. Although there were no associated neurologic symptoms, the patient described intermittent fever and chills.73-Year-Old Woman With Progressive Shortness of Breath
A 73-year-old woman presented to our institution for evaluation of progressive shortness of breath that had gradually worsened during the previous year. Initially, her symptoms were mild and noticeable only with moderate exertion. By presentation, however, she reported severe dyspnea with only minimal exertion. Walking 3 to 6 meters resulted in such severe dyspnea that she had to discontinue activity. She also reported a harsh cough with occasional clear sputum production. A provisional diagnosis of asthma had been suggested before her presentation.83-Year-Old Woman With Abdominal Distention and Constipation
An 83-year-old woman with Alzheimer dementia presented to the emergency department with abdominal distention. Her husband provided the history. After having constipation for 1 week, she developed a progressively distended abdomen in the course of 2 days, with anorexia but no vomiting, melena, or hematochezia. She had no history of fever, rigors, dyspnea, or weight loss. Her medical history was remarkable for hypertension, coronary artery disease, and impaired fasting blood glucose levels. Despite the recent symptoms, she had no history of gastroenterologic symptoms, cancer, abdominal surgeries, or colon screening studies.65-Year-Old Man With Persistent Fever
A 65-year-old man was transferred to our institution for evaluation of fever. His symptoms included subjective fever, cough productive of creamy white sputum, and nasal congestion of 3 months' duration. He denied dyspnea, hemoptysis, weight loss, or night sweats. Approximately 10 days before admission, he had been seen by his primary care physician for worsening of symptoms and was treated empirically with an undefined antibiotic. Subsequently, palpitations and severe fatigue developed, and the patient was admitted to a local hospital, where he was noted to be febrile and hypoxic with pulse oximetry readings in the high 80% range.42-Year-Old Male Methamphetamine User With Dysarthria and Facial Droop
A 42-year-old man presented to the emergency department after the sudden onset of left hand numbness and tingling, dysarthria, and right-sided temporal region pain that began 30 minutes previously. On his way to the hospital, the patient had developed bilateral flank pain. He denied any significant medical history or history of similar symptoms and stated he had been in his usual state of health until the sudden onset of symptoms that brought him to the emergency department. He denied taking any medications and had no history of stroke, head trauma, recent bleeding, chest pain, back pain, palpitations, fevers, or chills.
