Residents' Clinics
54-Year-Old Man With Excessive Belching
A 54-year-old man was evaluated for excessive belching at the resident clinic. He started noticing bothersome belching approximately 2 years ago that had progressively worsened. He described belching about 40 to 50 times in an hour. His symptoms were triggered by carbonated beverages and spicy foods and sometimes abated by taking slow deep breaths. He denied drinking caffeinated beverages, chewing gum, using nonsteroidal anti-inflammatory drugs (NSAIDs), eating fast, or having large amounts of food at a single seating.40-Year-Old Man with Dysphagia
A 40-year-old man presented to the emergency department with a 1-month history of worsening weakness, dysphagia, cough, and anxiety. His medical history was significant for schizoaffective disorder and type II bipolar disorder. At present, medications include paliperidone injection every 30 days, risperidone 6 mg at bedtime, and haloperidol deaconate 200 mg intramuscularly every 2 weeks, which he was recently initiated during a 3-month inpatient psychiatric stay for nonadherence to medication. The patient resides in a group home, and the staff reported compliance with his current medication regimen.51-Year-Old Woman With Fever, Cough, and Myalgias
A 51-year-old woman presented to the emergency department (ED) during the summertime with a 2-day history of fever up to 39.2 °C, nonproductive cough, myalgias, and nausea without associated diarrhea or vomiting. Her medical comorbidities included nicotine dependence with a 20-pack-year smoking history, common variable immune deficiency, quiescent multiple sclerosis not receiving immunomodulatory therapy, heart failure with preserved ejection fraction, hypertension, and fibromyalgia. Medications at the time of presentation were nortriptyline, cyclobenzaprine, aspirin, and duloxetine.50-Year-Old Man With Hematochezia and Fatigue
A 50-year-old man, originally from southern Mexico, presented to primary care clinic for evaluation of intermittent bright red blood per rectum (BRBPR). His medical comorbidities included type 2 diabetes, hypothyroidism, and well-controlled hypertension. He had a history of cholecystectomy in Mexico many years ago, with an unspecified complication requiring laparotomy and partial small-bowel resection. His medications included metformin, glimepiride, lisinopril, levothyroxine, atorvastatin, and low-dose aspirin.25-Year-Old Man With Fever, Diarrhea, and Weight Loss
A 25-year-old male immigrant from Central America presented to the emergency department with fever, general abdominal discomfort, nausea, watery diarrhea (10 to 15 bowel movements daily), and a 9-kg weight loss of 1 month’s duration. He did not have headache, photophobia or phonophobia, vision changes, dysphagia or odynophagia, chest pain, dyspnea, bloody stool, rash, or arthralgias. He had immigrated to the United States 3 years previously and lived in both Florida and Minnesota. He worked as a migrant laborer on a tomato farm.62-Year-Old Man With Abdominal Pain
A 62-year-old man presented to the emergency department with 3 days of sudden-onset right lower-quadrant abdominal pain. The pain was constant, dull in character, nonradiating, worse immediately after meals, and associated with nausea. It was alleviated by sitting in a hot tub. He denied fever or changes in stool. He had no history of recent travel, eating unusual foods, or sick contacts. For the previous 6 months, he had been using injectable testosterone and anastrozole, prescribed by his naturopathic provider for hormonal replacement therapy.46-Year-Old Woman With Type 2 Diabetes Mellitus and Obesity
A 46-year-old woman presented to her internist for evaluation of type 2 diabetes mellitus (T2DM) and obesity.38-Year-Old Woman With Chest Pain
A 38-year-old woman presented to the emergency department (ED) with abrupt onset left-sided chest pain. She described the pain as intense, sharp, and radiating to her left arm, with associated nausea and diaphoresis. Her medical history was notable for fibromuscular dysplasia of the renal arteries complicated by renovascular hypertension status post angioplasty, posttraumatic stress disorder, and former tobacco use. Her daily home medications included aspirin, hydroxyzine, lisinopril, sertraline, and trazodone.49-Year-Old Man With Fever, Night Sweats, Palpitations, and Shortness of Breath
A 49-year-old man presented to the clinic reporting fever, night sweats, palpitations, and shortness of breath. He had been experiencing symptoms for the past 6 weeks, starting with severe fatigue after a usual 7-mile run, followed by 2 weeks of intermittent fever and 4 weeks of dry cough and night sweats. During this time, he experienced 10-lb weight loss and physical activity was limited by shortness of breath; he was also experiencing intermittent palpitations. At baseline he was able to run up to 15 miles, but experienced substantial loss of exercise tolerance and was no longer able to sustain prolonged running.82-Year-Old Man With Chest Pain and Shortness of Breath
An 82-year-old man presented to the emergency department with chest pain. His pain started one day before admission; it was intermittent, substernal, and pressure-like in nature. Gradually, the pain progressed and became constant. In addition, the patient developed shortness of breath and lower-extremity swelling.81-Year-Old Man With Episodic Spells of Weakness, Fatigue, and “Shakes”
An 81-year-old Mediterranean man presented to the emergency department with 6 months of episodic nervousness, warmth, sweating, and hunger that would subsequently progress to weakness, fatigue, difficulty concentrating, and “feeling shaky.” He denied loss of consciousness, dizziness, palpitations, chest pain, dyspnea, and post-event weakness. Symptoms occurred throughout the day and night and resolved by consuming snacks or juice. The patient thus consumed frequent scheduled meals throughout the day and night.76-Year-Old Woman With Hemoptysis
A 76-year-old woman presented with 2 years of hemoptysis that had been increasing in frequency until it was happening on a daily basis. She had also experienced new hypoxia, exertional dyspnea, fatigue, and weight loss. Her past medical history was pertinent for severe scoliosis, remote myocardial infarction, heart failure with preserved ejection fraction (HFpEF), mild aortic stenosis, hypertension, and chronic kidney disease stage IV. She had no history of atrial fibrillation. Her medications included aspirin, high-intensity atorvastatin, furosemide, metoprolol tartrate, and lisinopril.61-Year-Old Man With Bilateral Leg Pain, Abdominal Pain, and Thrombocytopenia
A 61-year-old man presented to the emergency department with a 10-day history of nausea, vomiting, subjective fevers and chills, body aches, decreased urine output, and periumbilical abdominal pain. He denied diarrhea, chest pain, dyspnea, or urinary symptoms. Ten days earlier, he had returned from a 9-day trip to Jamaica with his wife, during which time she experienced 5 days of diarrhea, vomiting, and fevers but had since recovered. His medical history was notable for paroxysmal atrial fibrillation and gastroesophageal reflux disease.46-Year-Old Man With Presyncope and Rash
A 46-year-old man presented to the emergency department in early September after an episode of presyncope. He had also been experiencing fever, headaches, myalgias, and fatigue for 2 weeks. His medical history was significant for diet-controlled type 2 diabetes. He was not taking any medications or supplements. The patient was from the Upper Midwest and had recently been hiking and camping several times throughout the summer. He endorsed multiple mosquito bites but denied any tick exposure. He had no international travel within the past 10 years and denied any recent travel outside the Midwest.70-Year-Old Man With Dizziness and Nausea
A 70-year-old man presented to the emergency department for intermittent dizziness, nausea, and weakness over the past 3 months. His symptoms had been worsening over the past week, and he was vomiting after any oral intake for the past 2 days. Review of systems was notable for fatigue, confusion, forgetfulness, 9-lb weight loss, and worsening chronic dry cough. He denied fever, chills, headache, shortness of breath, chest pain, abdominal pain, constipation, kidney stones, urinary frequency, or pain with urination.20-Year-Old Postpartum Woman With Hypoxia and Tachycardia
A 20-year-old Gravida 1 Para 0 (G1P0) woman 38 weeks pregnant was admitted for delivery. She had no known comorbidities and was taking no medications. The pregnancy was uncomplicated. Laboratory results revealed a hemoglobin level of 15.0 g/dL (normal range, 11.6-15.0 g/dL), a hematocrit level of 45.0% (35.5%-44 .9%), leukocytosis with a white blood cell count of 12.2×109/L ((3.4-10.6)×109/L), and erythrocytosis with a red blood cell count of 5.51×1012/L ((3.92-5.13)×1012/L). She had an uncomplicated spontaneous vaginal birth with the use of local anesthesia as well as an estimated blood loss of 75 mL.57-Year-Old Man With Headache, Vomiting, and Gait Instability
A 57-year-old man, originally from Burma, presented to the emergency department with headache, nausea, vomiting, and unsteadiness in December 2020. He had no significant medical history and was not taking any medication.37-Year-Old Man With Headache and Nasal Congestion
A 37-year-old man with obesity and type 2 diabetes mellitus presented to his primary care physician with 4 days of headache, congestion, and nasal drainage. His headache was dull, aching, and involved his entire head, though there was an occasional throbbing quality pain in his bilateral cheeks (just below the eyes) and forehead. Nasal congestion was his most bothersome symptom, and he felt so “stuffy” that it was difficult to breath at night. He reported green drainage from the nose with brownish streaks.62-Year-Old Woman With Diarrhea, Vomiting, and Chest Pain
A 62-year-old woman presented to an outside emergency department with a 24-hour history of vomiting-associated chest pain. She described a nonradiating retrosternal ache with dyspnea and diaphoresis after multiple episodes of nonbilious and severe vomiting. Recent history was notable for amoxicillin/clavulanic acid–treated colitis. After failure to improve, she was diagnosed as having Clostridium difficile and completed 10 days of treatment with vancomycin. Two weeks prior to presentation, fidaxomicin was initiated because of persistent symptoms and ongoing stool positivity.71-Year-Old Man With a New Heart Murmur
A 71-year-old man with a history of hypertension, hyperlipidemia, and bicuspid aortic valve endocarditis treated with prosthetic valve replacement in 2012 presented to the internal medicine clinic for his annual physical examination. His home medications included aspirin (81 mg), pantoprazole (40 mg), paroxetine (37.5 mg), rosuvastatin (20 mg), and terazosin (10 mg) daily. Review of systems was notable for increasing exertional and supine shortness of breath. He also reported occasional chest discomfort on the right side with and without exertion.39-Year-Old Woman With Severe Weakness
A 39-year-old woman presented to the emergency department (ED) with progressive weakness. Her medical history was notable for iron deficiency anemia, gastroesophageal reflux disease (GERD), and obesity after Roux-en-Y gastric bypass 10 years previously. Active home medications included omeprazole (40 mg daily) and 2 recent intravenous (IV) infusions of ferumoxytol (510 mg elemental iron per dose). Several months prior to her ED presentation, the patient experienced tingling in both hands and feet, new-onset dyspnea with climbing stairs and sexual activity, and intermittent episodes of fatigue, which gradually increased in frequency and severity.65-Year-Old Man With Weight Loss and Dyspnea on Exertion
A 65-year-old man, a nonsmoker, presented to the hospital in mid-February 2021 with a 30- to 40-lb weight loss over 2 to 3 months and profound fatigue. He also endorsed dyspnea on exertion, a productive cough, and profuse watery diarrhea for several days. Clinical comorbidities included a diagnosis of Mantle cell lymphoma (MCL) in remission after treatment with chemotherapy (cyclophosphamide, vincristine, doxorubicin), autologous stem cell transplant (ASCT) in May 2019 and maintenance rituximab every 8 weeks, hypogammaglobinemia, hypertension on lisinopril, type 2 diabetes mellitus (T2DM) on metformin, and coronary artery disease on aspirin and atorvastatin.43-Year-Old Woman With Painful Jaundice
A 43-year-old woman with a medical history of stage IIIB cutaneous melanoma previously receiving adjuvant immunotherapy with nivolumab presented to the emergency department with a 4-day history of nausea, vomiting, abdominal pain, and jaundice. Symptoms began with nausea and vomiting after eating a meal. The following morning she had dull right upper quadrant and periumbilical abdominal pain. Her nausea persisted, and she had multiple episodes of nonbloody nonbilious emesis. Later that day, she developed jaundice and had fever and chills, which prompted her presentation to the emergency department.24-Year-Old Woman With Menorrhagia, Mucosal Bleeding, and Easy Bruising
A 24-year-old woman with a complex medical history including Ehlers-Danlos syndrome with hypermobility subtype, mast cell activation syndrome, eosinophilic esophagitis, and postural orthostatic tachycardia syndrome (POTS) presented to the emergency department (ED) for evaluation of menorrhagia, muscle cramps, and fatigue of 3 weeks’ duration. Her home medications included albuterol (90 μg/inhaler to be used every 6 hours as needed), cyanocobalamin (1000 μg daily), diphenhydramine (50 mg twice a day), epinephrine (0.3 mg/0.3 mL by auto-injector as needed), fexofenadine (180 mg twice a day), ketotifen (2 mg twice a day), and montelukast (10 mg daily at bedtime).69-Year-Old Man With Dysuria and Right Lower Abdominal Pain
A 69-year-old man presented to the emergency department (ED) with new-onset dysuria, urinary frequency and urgency, and right lower quadrant abdominal pain of 5-hour duration. His medical comorbidities included benign prostatic hyperplasia, obesity, hypertension, and hyperlipidemia. He also noted nausea and 3 episodes of nonbloody, nonbilious emesis. For the past week, he reported severe colicky right flank pain, which he attributed to musculoskeletal pain, that was partially relieved by taking no more than 1 tablet of an over-the-counter nonsteroidal anti-inflammatory drug daily.
