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Diagnostic Dilemma
It All Depends: A Case of a Position-Dependent Intracardiac Shunt
An 87-year-old woman presented to clinic for evaluation of knee pain. On arrival, vital signs showed oxygen saturation (SpO2) of 87%-88% on room air. She had no chest pain or dyspnea and had ambulated to the clinic without assistive devices or resting. Medical history included hypertension, acid reflux, and incompletely treated latent tuberculosis. Home medications included losartan and omeprazole. Her hypoxia persisted on multiple rechecks, and she was placed on supplemental oxygen (O2) and referred to the emergency department (ED).Not Your Typical Hemorrhagic Pleural Effusion
A 36-year-old white man with a 20 pack-year smoking history, childhood asthma, and previous heavy alcohol use presented with progressive dyspnea on exertion and chest tightness for the past month. He lived in the Los Angeles area, but frequently hiked in the Southern California area, including twice in the past year around Bakersfield, and after one trip about 9 months prior, noted a febrile illness that he felt may have been related to an insect bite. He was seen in our Emergency Department with a low-grade fever (T = 38.06°C [100.5°F], tachycardia to 142 beats per minute) and sharp right-sided head pain.Hyperfibrinolysis: An Uncommon Cause of Bleeding in Cirrhosis
A 57-year-old man with past medical history of alcohol use disorder and cirrhosis presented with right leg pain after a fall at home. Imaging revealed a large right thigh hematoma, and he underwent placement of a Jackson-Pratt (JP) drain by interventional radiology. The hematoma began draining about 100 mL of serosanguineous fluid per day. Laboratory studies showed a hemoglobin of 10.0 g/dL, platelets of 113 k/cm2, international normalized ratio (INR) of 1.5, total bilirubin of 3.8 mg/dL, aspartate transaminase (AST) of 79 IU/L, alanine transaminase (ALT) of 20 IU/L, and alkaline phosphatase (ALP) of 170 IU/L.Miliary Tuberculosis in an Immunocompetent Male with Central Nervous System Involvement
The patient was a 51-year-old male from Mexico with no known significant past medical history who presented with several weeks of intermittent fevers, chills, night sweats, headaches, and weight loss. The headaches, fevers, chills, and night sweats had begun 2 months prior to this admission. One week prior to this admission, he had presented to another institution with a chief complaint of persistent headaches. At the outside hospital, the patient was found to have a positive Quantiferon Gold test.A Cerebrospinal Case of Dyspnea
A 63-year-old male presented to the emergency department of our hospital with a 1-week history of new onset of dyspnea. His past medical history was remarkable only for a recently diagnosed prolactin producing pituitary macroadenoma discovered during an emergency department visit for mild coronavirus disease (COVID-19) infection. He was being followed in the ambulatory endocrinology clinic for workup and had recently been started on oral cabergoline for treatment.More Than Meets the Eye: A Patient with Hand Swelling and Newly Diagnosed Diabetes Mellitus
The patient is a 72-year-old man with known history of hypertension on amlodipine and losartan. He presented to the hospital with bilateral hand pain and swelling, as well as bilateral shoulder pain and stiffness with restricted range of motion, of 2 weeks duration. The swelling was initially asymmetric and worse over the right hand, although there was no preceding trauma or fall, and no fever or infective symptoms.Facial Swelling and Pancytopenia: First Features and Clues to the Etiology of Acute Kidney Injury.
A previously healthy 45-year-old woman presented with facial swelling, abdominal bloating, and fatigue.Intravascular Large B Cell Lymphoma as a Cause of Multifocal Cryptogenic Stroke
The patient was a 66-year-old female with a history of left-sided breast cancer with prior lumpectomy and radiation, thyroid cancer status post-thyroidectomy who presented to the emergency department for difficulty finding words. She had unremarkable findings on computed tomography (CT) brain and electroencephalogram (EEG) testing. Three months later, she developed bilateral lower extremity weakness and was admitted to a local hospital. Bilateral embolic strokes were discovered on brain magnetic resonance imaging (MRI).Troubling Tenosynovitis: When a Serious Sign Persists
A 42-year-old woman was admitted to the hospital with 5 days of diffuse joint pain and swelling associated with prolonged morning stiffness and intermittent fevers up to 38.7°C. The review of systems was negative for rashes, mouth sores, pleuritic chest pain, alopecia, dysuria, vaginal discharge, diarrhea or vomiting, cough or shortness of breath, recent travel, sick contacts, or tick exposure. Her medical history was significant for a 2-year history of an undifferentiated connective tissue disease, which presented with inflammatory arthritis, palpable skin rashes (biopsy showed immunoglobulin G and immunoglobulin M granular deposition along the basement membrane zone, suggestive of a connective tissue disease), positive antinuclear antibodies, positive SS-A and SS-B, low total complement, low C3 and C4, and positive rheumatoid factor with negative anticyclic citrullinated peptide antibodies.An Elusive Case of Recurrent Gram-Negative Sepsis
An 85-year-old man was admitted to the hospital for evaluation of recurrent fever and chills.Paraneoplastic Thrombocytopenia
A 56-year-old man with a history of lisinopril-induced liver injury status post liver transplant 12 years prior, calcineurin inhibitor nephrotoxicity status post kidney transplant 2 years prior, and chronic BK viruria presented to the Emergency Department for evaluation of isolated thrombocytopenia. He was in his usual state of health when a complete blood count 3 weeks prior to presentation revealed a platelet count of 121,000/mm3. Previous platelet counts had been within normal limits, with a platelet count of 146,000/mm3 8 weeks prior to presentation.A Case of Paraneoplastic Pemphigus with Follicular Dendritic Cell Sarcoma
A 42-year-old female presented with an 8-week history of progressive generalized rash and mucocutaneous ulcers associated with 50-pound weight loss. She had no personal or family history of autoimmune disease. No recent illness or change in medications before the onset of her rash.A 77-Year-Old Man with Multiple Myeloma and a Lytic Bone Lesion
A 77-year-old patient with multiple myeloma and on lenalidomide developed a slowly progressive right upper thigh pain with no antecedent trauma. The status of his multiple myeloma was stable, and he did not have a history of osteolytic lesions. He had not received corticosteroids as part of his multiple myeloma therapy. He was found to have a right proximal femur lytic lesion (Figure 1) and received local radiation therapy for 2 months; however, the lytic lesion increased in size, associated with worsening pain and affecting his mobility and ability to carry his daily activities.
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