1. Dr. Zahoor 1

2. A 26 year old woman presents to the ER complaining of sudden onset of palpitations and severe shortness of breath and coughing. She reports that she experienced several episodes of palpitations in the past, often lasting a day or two, but never with dyspnea like this. She has a history of rheumatic fever at the age of 14 years. She is now 20 weeks pregnant with her first child and takes prenatal vitamins. She denies use of any other medications, tobacco and alcohol. 2

3. On examination, her heart rate is between 110 and 150 bpm and is irregularly irregular, with blood pressure of 92/65mmHg, respiratory rate of 24 breaths per minute and oxygen saturated of 94% on room air. She appears uncomfortable with laboured respirations. She is coughing, producing scant amounts of frothy sputum with pinkish tint. She has ruddy cheeks and a normal jugular venous pressure. She has bilateral inspiratory crackles in the lower lung fields. 3

4. On cardiac examination, her heart rhythm is irregularly irregular with a loud S 1, and low pitched diastolic murmur at the apex. Her apical impulse is nondisplaced. Her uterine fundus is palpable at the umbilicus, and she has no peripheral edema. An ECG is obtained: 4

5. 1. What is the most likely diagnosis? 2. What is your next step? 5

6. 1. Atrial fibrillation caused by mitral stenosis 2. Cardiac rate control with intravenous beta blockers 6

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8. A 42 year old woman presents to the ED complaining of 24 hours of severe, steady epigastric abdominal pain, radiating to her back, with several episodes of nausea and vomiting. She has experienced similar painful episodes in the past, usually in the evening following heavy meals, but the episodes always resolved spontaneously within an hour or two. This time the pain did not improve, so she sought medical attention. She has no medical history and takes no medications. She is married, has three children, and does not drink alcohol or smoke. 8

9. On examination, she is afebrile, tachycardiac with a heart rate of 104 bpm, blood pressure 115/74mmHg, and shallow respirations of 22 breaths per minute. She is moving uncomfortably on the stretcher, her skin is warm and she has scleral icterus. Her abdomen is soft, mildly distended with marked right upper quadrant and epigastric tenderness to palpation, hypoactive bowel sounds, and no masses or organomegaly appreciated. Her stool is negative for occult blood. 9

10. Laboratory studies are significant for a total bilirubin (9.2mg/dL) with a direct fraction of 4.8mg/dL. Alkaline phosphatase 285 IU/L (N: 39 – 117) Aspartate aminotransferase (AST) 78 IU/L (N: 12-40) Alanine aminotransferase (ALT) 92 IU/L (N: < 40) Amylase level 1249 IU/L (N: 25-125) Her leukocyte count is 16,500/mm 3 with 82% polymorphonuclear cells and 16% lymphocytes. A plain film of the abdomen shows a non specific gas pattern and no pneumoperitoneum. 10

11. 1. What is the most likely diagnosis? 2. What is the most likely underlying etiology? 3. What is your next diagnostic step? 11

12. 1. Acute pancreatitis 2. Choledocholithiasis (common bile duct stone) 3. Right upper quadrant abdominal ultrasonography 12

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14. A 58 year old man comes to see you because of shortness of breath. He has experienced mild dyspnea on exertion for a few years, but more recently he has noted worsening shortness of breath with minimal exercise and the onset of dyspnea at rest. He has difficulty reclining and as a result, he spends the night sitting up in a chair trying to sleep. He reports a cough with production of yellowish brown sputum every morning throughout the year. 14

15. He denies chest pain, fever, chills, or lower extremity edema. He has smoked about two packs of cigarettes per day since age 15 years. He does not drink alcohol. A few month ago, the patient went to clinic for evaluation of his symptoms, and received a prescription for some inhalers, the names of which he does not remember. He was also told to find a primary care physician for further evaluation. 15

16. On physical examination, his blood pressure is 135/85mmHg, heart rate 96bpm, respiratory rate 28 breaths per minute and temperature 97.6 o F. He is sitting in a chair, leaning forward, with his arms braced on his knees. He appears uncomfortable with laboured respirations and cyanotic lips. He is using accessory muscles of respiration and chest examination reveals wheezes and rhonchi bilaterally, but no crackles are noted. 16

17. The anteroposterior diameter of the chest wall appears increased, and he has inward movement of the lower rib cage with inspiration. Cardiovascular examination reveals distant heart sounds but with a regular rate and rhythm, and his jugular venous pressure is normal. His extremities show no cyanosis, edema, or clubbing. 17

18. 1. What is the most likely diagnosis? 2. What is the next best diagnostic test? 3. What is the best initial treatment? 18

19. 1. Chronic Obstructive pulmonary disease (COPD) with acute exacerbation 2. Arterial blood gas to assess oxygenation and acid base status 3. Oxygen by nasal cannula, followed closely by bronchodilators and steroids for inflammatory component 19

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