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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.
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