A 21-year-old man presents to the Emergency Department complaining of nausea, vomiting, and severe headache for the past 24 hours, which increases in severity while lying flat. On examination, his temperature is 38.5°C, blood pressure is 140/85 mmHg, and heart rate is 105 beats per minute. His neck is stiff. Lumbar puncture is performed but the results are pending.
What is the most appropriate course of action at this time?
Begin ceftriaxone, vancomycin, and acyclovir. This patient’s presentation is most consistent with meningitis, and bacterial and viral causes are most concerning in this patient given the acute presentation. (B) Empiric antibiotics should be started immediately after the lumbar puncture is performed. Ceftriaxone and vancomycin are appropriate coverage for Streptococcus pneumoniae, Neisseria meningitidis, and Haemophilus influenzae, the most common pathogens involved in patients aged 3 months to 50 years of age. Acyclovir is an appropriate addition if a viral etiology such as HSV is suspected. (A, D) Ceftriaxone alone would not cover resistant S. pneumoniae strains, and ampicillin is unnecessary given the low incidence of Listeria meningitis in patients between the ages of 3 months and 50 years. (E) A CT scan of the head may be performed before a lumbar puncture if there is a suspicion for a space-occupying lesion, but the lumbar puncture has already been performed.
A 65-year-old Russian man presents to the Emergency Department at 2 am complaining of chest pain. No one is available to translate at this time. His wife produces limited records from an outside hospital from an admission 6 weeks ago, which includes an ECG performed at that time. On examination, his temperature is 37.0°C, blood pressure is 140/85 mmHg, and heart rate is 95 beats per minute. He is mildly diaphoretic, and his apical impulse is displaced to the left of the midclavicular line. An S3 is heard on auscultation. He has no jugular venous distention or lower-extremity edema. A 12-lead ECG is performed and shows ST elevations in the anterior leads, which is unchanged from the ECG performed 6 weeks ago from the outside hospital.
What was the most likely diagnosis made during the patient’s admission to the outside hospital 6 weeks ago?
ST elevation myocardial infarction. This patient most likely presents with a left ventricular aneurysm, which is a late complication of ST elevation myocardial infarction (STEMI). Left ventricular aneurysms typically present 2 weeks to several months after an MI. Physical examination may reveal cardiac enlargement with a displaced apical impulse and an S3, indicating blood flow into a dilated ventricular chamber. ST elevations may persist from the original myocardial infarction, as evidenced on this patient’s serial ECGs. (A) Postinfarct pericarditis presents with pleuritic chest pain, fever, and pericardial friction rub on examination within 24 hours of the infarction. ECGs may show diffuse ST elevation, but would not localize to a vascular territory such as in this patient. Dressler syndrome could present 6 weeks after infarction but signs of pericarditis (as above) should be present. (B) Interventricular septal rupture is a severe complication of MI, and often presents with shock and signs of cardiac tamponade. (D) Myocarditis is typically due to a viral illness and would likely be associated with fever and signs of congestive heart failure, which are absent in this patient. (E) The patient does not have jugular venous distention or lower-extremity edema, and the previous ECG showed ST elevations.
A 72-year-old woman with hypertension and hyperlipidemia presents to the clinic with a primary complaint of constipation. Her medications include a “water pill,” a statin, and a daily multivitamin. Her laboratory tests demonstrate the following:
What is most likely responsible for the patient’s complaint and laboratory findings?
Hydrochlorothiazide. Thiazide diuretics are the most likely cause of this patient’s elevated calcium levels; they also cause hyponatremia, hypercalcemia, and hyperglycemia, which are seen in this patient. (B, C) Both primary and secondary hyperparathyroidism would have an elevated parathyroid hormone (PTH); secondary hyperparathyroidism would have hypocalcemia. (D) Malignancy will generally produce more elevated calcium levels. (E) A typical multivitamin would not cause excessive vitamin D levels.
A 28-year-old woman presents for a routine clinic appointment. She has no past medical history and does not take any medications. On examination, a thyroid nodule is palpated. Laboratory studies show a TSH of 1.4 μU/mL. An ultrasound is performed and a single nodule is visualized with a width of 1.2 cm.
What is the next best step in management?
Fine needle aspiration biopsy. Nonfunctioning thyroid nodules (indicated by a normal or high TSH) should be biopsied to rule out malignancy. (A) Reassurance is only appropriate after malignancy is excluded. (B) Medical management with methimazole or propylthiouracil is an option for someone with hyperthyroidism due to Graves disease. (C) Radioactive ablation is the definitive treatment for Graves disease. (D) A radioactive iodine uptake study (scintigraphy) would be helpful to confirm a hyperfunctioning nodule if the TSH were low. If this had been the case, a fine needle aspiration biopsy would not have been necessary. Surgery is too invasive at this stage of the workup but may be performed if the biopsy results are suspicious or confirm malignancy.
A 40-year-old man comes to the cardiology clinic for a follow-up visit regarding his complete heart block. He recently had a pacemaker placed, and states that he is doing well. When you shake his hand, you notice that the patient has difficulty releasing his grip, and upon questioning he seems to have significant difficulty with concentration. His past surgical history is significant for bilateral cataract surgery.
What further testing should be done to confirm this man’s additional diagnosis?
No further testing needed. Myotonic dystrophy is an autosomal dominant disease that affects multiple systems, producing myotonia (delayed relaxation of skeletal muscle), muscle weakness, cardiac conduction abnormalities, insulin resistance, and cataracts. Myotonic dystrophy is largely a clinical diagnosis, especially with such a characteristic constellation of symptoms/signs. (B) Genetic testing to diagnose specific variants is possible, but not required. Therefore, no further testing is needed. (A) Muscle biopsy may show some abnormalities but is not a very useful test. (C) Serum CK will be mildly elevated but is nonspecific. (D) Temporal artery biopsy is an important diagnostic step in temporal (giant cell) arteritis.
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