Residents' Clinics
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.47-Year-Old Man With Dizziness and Palpitations
A 47-year-old man with no significant past medical history presented to the emergency department with sudden-onset palpitations. He denied any recent fevers, chills, or unexpected weight loss. He had no recent sick contacts and no pertinent travel. He reported moderate alcohol intake, did not smoke, and was not on any medications at the time.28-Year-Old Man With Joint Pain
A 28-year-old man presented to the emergency department with right shoulder pain that radiated to the right arm as well as pain of the right hip and lower back. His medical history is significant for sickle cell disease (SCD) with the HbSS genotype (homozygous for the S globin). He had a hemorrhagic stroke in the setting of venous sinus thrombosis 2 years earlier with no persisting neurologic deficits as well as osteonecrosis of bilateral hips and right knee requiring right total hip arthroplasty and right total knee arthroplasty.46-Year-Old Woman With Fever, Myalgia, and Headache
A 46-year-old Hispanic woman presented to a Minnesota emergency department in late fall 2020 with 5 days of fever (38.3°C), chills, malaise, headache without photophobia, epistaxis with loss of smell, gingival bleeding when brushing her teeth, nonproductive cough, diarrhea, and diffuse myalgia when driving home from a trip just across the Texas-Mexico border. She never had similar symptoms before, but has traveled to Mexico on multiple occasions. Her exposures in Mexico included domesticated dogs, mosquito bites, local food, and sexual intercourse while in a monogamous relationship.55-Year-Old Man Presenting With Jaundice
A previously healthy 55-year-old man presented to our outpatient clinic with several days of jaundice, pruritus, acholic stools, and dark-colored urine. Three weeks before, he had completed a course of amoxicillin-clavulanic acid for an acute upper respiratory infection. The patient denied excessive alcohol intake, foreign travel, or recent sick contacts. He did not take regular medications or herbal supplements and had no personal or family history of liver disease.20-Year-Old Man With Elevated Liver Tests
A 20-year-old Hispanic man presented for evaluation to a primary care physician before studying abroad for his upcoming college semester. He had no specific complaints, and his past medical history was notable for mild asthma. He used an albuterol inhaler intermittently and otherwise was taking no medications. His blood pressure was 120/80 mm Hg, heart rate 80 beats per minute, and body mass index 23.4 kg/m2. On physical examination, he had a regular rate and rhythm without murmurs, his lungs were clear to auscultation, and his abdomen was soft, nontender, and without hepatomegaly.58-Year-Old Woman With Cough and Dyspnea
A 58-year-old woman presented to the emergency department with a 5-month history of worsening cough and new-onset exertional dyspnea. She reported back pain, palpitations, recent sinus congestion, subjective fevers, poor appetite, and night sweats. Her past medical history included hypertension and hyperlipidemia. The patient was taking amlodipine, lisinopril, and simvastatin and was recently prescribed levocetirizine for sinus congestion. She resided in Kansas but had been traveling to and from Arizona, with her last trip being 23 days ago on a 19-hour car trip.24-Year-Old Man With Syncope
A 24-year-old man with a past medical history of tobacco use and generalized anxiety disorder presented to the emergency department by ambulance after being found unresponsive by his mother at home. There was associated loss of consciousness and bladder control. Despite being unresponsive at home, he arrived alert and oriented but appears tired. He reports taking 300 mg of loperamide hydrochloride (maximum recommended dose is 16 mg/d) to achieve a high approximately 10 hours before arrival in the emergency department; he does not take any other medications.55-Year-Old Woman With Abnormal Liver Test Results
A 55-year-old woman is being evaluated for persistently elevated liver enzymes. She has no signs or symptoms of any liver disease, including jaundice, scleral icterus, and hepatosplenomegaly. Two months before presentation, she was incidentally noted to have aminotransferase values elevated to 3 times the upper limit of normal. At this time, aspartate transaminase (AST) was 256 U/L (8 to 43 U/L) and alanine transaminase (ALT) was 386 U/L (7 to 45 U/L). Five weeks later, aminotransferase determinations were repeated, and levels had increased further (AST, 422 U/L; ALT, 616 U/L).18-Year-Old Man With Chest Pain
A previously healthy 18-year-old man presented with chest pain that awoke him. The pain was described as constant, grade 2/10, left-sided chest pressure without radiation or correlation with exertion. This was preceded by 1 day of nausea, vomiting, and fever to 102℉. He did not have dyspnea, diaphoresis, palpitations, edema, orthopnea, risk factors for venous thromboembolism, recent travel, acute life stressors, trauma, or known connective tissue disorders. He did not have any chronic medical conditions and was not taking any medications as an outpatient.56-Year-Old Woman Presenting With Fatigue, Weakness, and Malaise
A 56-year-old woman presented to an outside emergency department with a history of several years of chronic symptoms including fatigue, weakness, and malaise. The patient had experienced abdominal discomfort and diminished appetite with some unintentional weight loss. She also reported diffuse myalgias and arthralgias that have been progressively worsening in severity.67-Year-Old Woman With Diarrhea and Weight Loss
A 67-year-old woman presented to clinic with a 2-year history of diarrhea, nausea, vomiting, and unexplained weight loss of 50 pounds. She described 3 or 4 bowel movements per day, consisting of watery stools without identifiable triggers. She also noted an intermittent rash on her lower extremities bilaterally. She denied fever, abdominal pain, hematochezia, or melena. Her medical history was notable for lifestyle-controlled hypertension and nonerosive gastroesophageal reflux disease. Her medications included omeprazole 20 mg daily and a daily vitamin B12 supplement.75-Year-Old Woman With Abdominal Pain and Constipation
A 75-year-old woman presented to the emergency department with a 1-year history of worsening loose stools and abdominal discomfort. Over the course of the year, the patient had experienced regular cycles of liquid stool followed by constipation for the next few days. She had recently started taking loperamide on the days she had diarrhea as recommended by her primary care provider. She denied hematochezia, melena, nocturnal stooling, weight loss, or recent travel. She had a normal screening colonoscopy 4 years prior.47-Year-Old Woman With Bilateral Flank Pain
A 47-year-old woman with a history of myeloperoxidase–anti-neutrophil cytoplasmic autoantibody (MPO-ANCA) microscopic polyangiitis (MPA) in remission, left orbital plasmacytoma in remission, and hypothyroidism presented to the hospital for 1 month of persistent bilateral flank pain. Additionally, she had 2 months of migratory joint pain and a rash that was briefly treated with hydroxychloroquine. Treatment was discontinued because of gastrointestinal upset. Upon evaluation, she also had complaints of mild sinus congestion and right ear fullness, but denied any shortness of breath, fever, chills, cough, hemoptysis, dysuria, urinary frequency and urgency, or routine use of protein pump inhibitors, nonsteroidal anti-inflammatory drugs, diuretics, herbal supplements, or illicit drugs.61-Year-Old Man With Nausea and Vomiting
A 61-year-old man with a past medical history of type 1 diabetes mellitus, hypertension, hyperlipidemia, and alcohol use disorder presented to the emergency department with epigastric abdominal pain, nausea, and vomiting. He normally consumed 4 to 6 cans of beer per day and had done this for numerous years. His last drink was 2 days before presentation, when he had his usual amount of alcohol intake. Home medications included aspirin 81 mg, atorvastatin 10 mg, and an insulin pump. The insulin pump used aspart.44-Year-Old Man With Anemia, Thrombocytopenia, and Acute Kidney Injury
A 44-year-old man presented with a 3-month history of progressive generalized weakness, polyarthralgia, polymyalgia, fatigue, unintentional 11 kg (13%) weight loss, and vision loss. His medical history is significant for hypothyroidism, melanoma in remission, spongiotic dermatitis that resolved with prednisone, Raynaud disease, and recently diagnosed monoclonal gammopathy of undetermined significance (MGUS). His ongoing medications include levothyroxine (75 ug), lisinopril (20 mg), omeprazole (40 mg), prednisone (40 mg), sulfamethoxazole-trimethoprim (400 to 80 mg), sumatriptan (50 mg as needed), and zolpidem (5 mg as needed).75-Year-Old Man With Fever and Malaise
A 75-year-old Caucasian man presented to the emergency department following an episode of unresponsiveness and urinary incontinence. Recent history revealed fever, fatigue, generalized weakness, increased urinary frequency, anorexia, and a 10-lb unintentional weight loss over several months. His medical history was significant for previous exposure to asbestos with pleural calcification; recent painless truncal and upper extremity rash with biopsy, demonstrating weak granular deposition of complement C3 (indeterminate for early connective tissue disease manifestation or normal variant); positive antinuclear antibody (ANA) titer of unknown clinical significance; esophageal stricture treated with dilation; type 2 diabetes mellitus treated with metformin; hypertension treated with amlodipine and enalapril; and hyperlipidemia treated with atorvastatin.52-Year-Old Woman With Palpitations, Abdominal Distension, and Severe Abdominal Pain
A 52-year-old woman presented to her local emergency department with acute-onset, nonradiating 9/10 abdominal, and right flank pain that started the day before. She denied any specific precipitating event and endorsed additional symptoms of progressive abdominal distention over the past 1 month, lower-extremity edema over the past 5 months, mild shortness of breath and dyspnea on exertion over the past 5 months, and intermittent palpitations over the past 6 years. Review of systems was otherwise negative.69-Year Old Man With Dysphagia and Nasal Regurgitation
A 69-year-old man presented to the gastroenterology clinic with a 2-month history of progressive difficulty initiating a swallow, accompanied by nasopharyngeal regurgitation and a sensation of residual food remaining in his throat. Accompanying symptoms included coughing and choking while eating, as well as excessive drooling. He would need to swallow repeatedly for proper passage of food and experienced regurgitation of fluid through his nose while swallowing. He had a 5-lb weight loss that he attributed to poor oral intake in the setting of gradually worsening symptoms during this time.91-Year-Old Man With Recurrent Falls
A 91-year-old man with probable Alzheimer dementia (Functional Assessment Staging Tool stage 6B, with no recent cognitive testing), major depressive disorder, insomnia, repeated falls, atrial fibrillation not on anticoagulation, hypertension, chronic kidney disease, urinary retention requiring self-catheterization, bilateral cataracts, osteoarthritis of the hips and lumbar spine, and constipation was seen in a memory-care unit after recent hospitalization for left hip fracture sustained in a ground-level fall.70-Year-Old Man With Chronic Nausea and Vomiting
A 70-year-old man with a medical history notable for gastroesophageal reflux disease, achalasia (status post Nissen fundoplication take down and hiatal hernia repair with later takedown and Heller myotomy with Dor fundoplication), chronic obstructive pulmonary disease, heart failure with preserved ejection fraction, chronic back pain, osteoarthritis, opioid use, insulin-dependent diabetes, diabetic neuropathy, and a diagnosis of gastroparesis presented with symptoms of altered mental status in the setting of intractable nausea and vomiting.
