Core Cases of the Month

July 2018

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Aphasia and R-sided hemiparesis

HPI

29yo FTM on testosterone cypionate, no other sig pmh, presents with worsening headache, expressive aphasia, and R sided hemiparesis. Pt had been having moderate L sided headache x 1 week prior to this presentation. No hx of headaches or migraines. Pt was at the theater with his sister, noticed some R sided hand weakness, but then was noted to have expressive aphasia by sister and brought to ED.

In ED pt had aphasia, R sided hand numbness, clumsiness, initial head CT negative, given tPA, and admitted to stroke unit. Over next 24 hours, pt had CT angiogram, MRI brain, MRV brain without evidence of ischemia, mass, or bleed. By this time aphasia and motor symptoms had resolved, although still with some headache.

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May 2018

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Malaise

HPI

45yo M with obesity, HTN, DM, GERD, EtOH abuse, presents feeling unwell and fatigued. Has mild HA, lightheadedness and for the past few days has been having polyuria with home FS in 300s. Was seen in ED yesterday with elevated FS, but given fluids with improvement in symptoms. Afterward, he saw his endocrinologist who adjusted his medications. Denies fever, abd pain, n/v/d, dysuria.

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April 2018

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AMS

HPI

62yF with h/o low back pain presents to ED decreased sensation to bilateral upper extremities, R>L. Family reports weight loss and increased muscle cramps for over 1 month. Stroke team activated, GCS 15, NIHSS score 1 (decreased sensation over hands). NCHCT is negative for ICH. EKG as shown.

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December 2017

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Chest pain

HPI

50yM no PMH, active smoker presents by ambulance with chest pain. Six hours ago he developed substernal chest pressure and nausea, no vomiting. Pain was moderate and constant, but he had a presyncopal episode 1hr prior and severe worsening of chest pain which led him to call 911. He was given ASA en route.

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November 2017

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Shortness of breath and abdominal pain

HPI

62yM PMH HTN, HLD, DM2, bioprosthetic MVR p/w shortness of breath and diffuse abdominal pain for three days. He c/o generalized malaise, nausea and multiple episodes of non-bloody, non-bilious emesis. He is concerned about elevated readings on his home glucometer. He is prescribed lisinopril, metoprolol, metformin and lantus. He denies alcohol or drug use. Denies fevers, chills, chest pain, palpitations, dizziness, diarrhea, dysuria, or recent trauma.

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October 2017

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AMS

HPI

52yM unknown PMH BIBEMS found minimally responsive in the field. The patient is undomiciled-appearing male found on a wet sidewalk in the rain. EMS administered 2 amps D50 IV, 2 mg Narcan IV, and 1L NS without improvement in mental status. He was seen in the ED two times in the previous month for IV heroin intoxication and was discharged after his mental status improved without intervention. On arrival he is lethargic and wet, mumbling incoherently and localizing to sternal rub and his breathing is spontaneous. EKG, CXR, POCUS of the heart are included. NCHCT was unremarkable.

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September 2017

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Fever and cough

HPI

59yF HIV on ART last CD4 716, undetectable VL, HTN, CKD p/w non-productive cough and fever x10d. 5d PTA she presented to the ED for dry cough, had CXR WNL, lab values WNL except Cr 3.2 and was discharged with f/u. Symptoms have continued since and she returns now because she has dyspnea at rest x 1d. Also c/o fatigue, chills and loose stools. She denies chest pain, headache, change in vision, rash, sick contacts or recent travel.

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August 2017

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Abdominal pain

HPI

27yF with h/o anxiety p/w abdominal pain x1d. Pain started yesterday evening, intermittent, a/w nausea and diaphoresis. Began as generalized pain but when supine, radiates to chest a/w mild SOB, otherwise localizes to the right abdomen with radiation to the pelvis.

Denies fever, chills, diarrhea, anorexia, blood in stool, recent travel, sick contacts. Sexually active with one male partner, denies STIs, uses OCPs, LMP 3 weeks ago. Denies vaginal bleeding or discharge.

The remainder of the patient’s labs other than those given are pending. On assisting the patient to the OBGYN room, she becomes markedly diaphoretic, lightheaded, tachycardic to 125, and hypotensive to SBP in the 60s. Repeat EKG shows sinus tach, portable CXR is unremarkable, and a RUSH bedside ultrasound exam notable for free fluid in the pelvis.

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