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CASE SCENARIO ,,, A 32 year old nurse presents to your office with a complaint of intermittent episodes of pain, stiffness, and swelling in both hands and wrists for approximately 1 year. The episodes last for several weeks and then resolve. More recently, she noticed similar symptoms in her knee and ankles. Joint pain and stiffness are making it harder for her to get out of bed in the morning and are interfering with her ability to perform her duties at work. The joint stiffness usually last for several hours before improving. She also reports malaise and easy fatigability for the past few months, but she denies having fever, chills, skin rashes, and weight loss. Physical examination reveals a well-developed woman, with blood pressure 120/70 mmHg, heart rate 82 bpm, and respiratory rate 14 breaths per minute. Her skin does not reveal any rashes. Head, neck, cardiovascular, chest, and abdominal examinations are normal. There is no hepatosplenomegaly. The joint examination reveals the presence of bilateral swelling, redness and tenderness of most proximal interphalangeal (PIP) joints, metacarpophalangeal (MCP) joints, the wrists, and the knees. Laboratory studies show a mild anemia with hemoglobin 11.2 g/dl, hematocrit 32.5%, mean corpuscular volume (MCV) 85.7 fL, white blood cell (WBC) count 7.9/mm3 with a normal differential, and platelet count 300,000/mm3. The urinalysis is clear with no protein and no red blood cells (RBCs). The erythrocyte sedimentation rate (ESR) is 75 mm/h, and the kidney and liver function tests are normal.

• What is your most likely diagnosis?
• What is your next diagnostic step?

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CASE SCENARIO ,,, A 48 year old man comes to your office complaining of severe right knee pain for 8 hours. He states that the pain, which started abruptly at 2 AM and woke him from sleep, was quite severe, so painful that even the weight of the bed sheets on his knee was unbearable. By the morning, the knee had become warm, swollen, and tender. He explains that he prefers to keep his knee bent, and extending his leg to straighten the knee causes the pain to worsen. He has never had pain, surgery, or injury to his knees. A year ago, he did have some pain and swelling at the base of his great toe on the left foot, which was not as severe as this episode, and resolved in 2 or 3 days after taking ibuprofen. His only medical history is hypertension, which is controlled with hydrochlorothiazide. He works as a financial analyst; he is married and does not smoke, but he does consume one or two drinks after work one to two times per week.
On examination, his temperature is 100.6F, heart rate 104 bpm, and blood pressure 136/78 mmHg. His head and neck examinations are unremarkable, his chest is clear, and his heart is tachycardic but regular, with no gallops or murmurs. His right knee is swollen, with a moderate effusion, and appears erythematous, warm, and very tender to palpation. He is unable to fully extend the knee because of pain. He has no other joint swelling, pain, or deformity, and no skin rashes.

• What is the most likely diagnosis?
• What is your next step?
• What is the best initial treatment?
   

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CASE SCENARIO ,,, A 48 year old Hispanic woman presents to your office complaining of persistent swelling of her feet and ankles, so much so that she cannot put on her shoes. She first noticed mild ankle swelling approximately 2-3 months ago. She borrowed a few diuretic pills from a friend; the pills seemed to help, but now she has run out. She also reports that she gained 20-25 lb over the last few months, despite regular exercise and trying to adhere to a healthy diet. Her medical history is significant for type 2 diabetes, for which she takes a sulfonylurea agent. She neither sees a doctor regularly nor monitors her blood glucose at home. She denies dysuria, urinary frequency, or urgency, but she does report that her urine has appeared foamy. She had no fever, joint pain, skin rashes, or gastrointestinal symptoms. Her physical examination is significant for mild periorbital edema, multiple hard exudates, and dot hemorrhages on funduscopic examination, and pitting edema of her hands, feet, and legs. Her chest is clear, her heart rhythm is regular without murmurs, and her abdominal examination is benign. She has diminished sensation to light touch in her feet and legs to mid-calf. A urine dipstick performed in the office shows 2+ glucose, 3+ protein, and negative leukocyte esterase, nitrates, and blood.

• What is the most likely diagnosis?
• What is the best intervention to slow the disease progression?

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CASE SCENARIO ,,, A 27 year old man presents to the outpatient clinic complaining of 2 days of facial and hand swelling. He first noticed swelling around his eyes 2 days ago, along with difficulty putting on his wedding ring because of swollen fingers. Additionally, he noticed that his urine appears reddish-brown and that he has had less urine output over the last several days. He has no significant medical history. His only medication is ibuprofen that he took 2 weeks ago for fever and sore throat, which have since resolved. On examination, he is afebrila, with heart rate 85 bpm and blood pressure 172/110 mmHg. He has periorbital edema: his funduscopic examination is normal without arteriovenous nicking or papilledema. His chest is clear to auscultation, his heart rhythm is regular with a nondisplaced point of maximal impulse (PMI), and he has no abdominal masses or bruits. He does have edema of his feet, hands, and face. A dipstick urinalysis in the clinic shows specific gravity of 1.025 with 3+ blood and 2+ protein, but it is otherwise negative.

• What is the most likely diagnosis?
• What is your next diagnostic step?

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CASE SCENARIO ,,, A 27 year old man comes to the emergency room complaining of 2 days of abdominal pain and diarrhea. He describes his stools as frequent, with 10-12 per day, small volume, sometimes with visible blood and mucus, and proceeded by a sudden urge to defecate. The abdominal pain is crampy, diffuse, and moderately severe, and it is not relieved with defecation. In the past 6-8 months, he has experienced similar episodes of abdominal pain and loose mucoid stools, but the episodes were milder and resolved within 24-48 hours. He has no other medical history and takes no medications. He has neither traveled out of the United States nor had contact with anyone with similar symptoms. He works as an accountant and does not smoke or drink alcohol. No member of his family has gastrointestinal problems.

On examination, his temperature is 99F, heart rate 98 bpm, and blood pressure 118/74 mmHg. He appears uncomfortable, is diaphoretic, and is lying still on the stretcher. His sclerae are clear, and his oral mucosa is pink and clear. His chest is clear, and his heart rhythm is regular, without murmurs. His abdomen is soft and mildy distended, with hypoactive bowel sound and moderate diffuse tenderness but no guarding or rebound tenderness.

Laboratory studies are significant for a white blood cell count of 15,800/mm3 with 82% polymorphonuclear leukocytes, hemoglobin 10.3 g/dL, and platelet count 754,000/mm3. the HIV assay is negative. Renal function and liver function tests are normal. A plain film radiograph of the abdomen shows a mildly dilated air-filled colon with a 4.5 cm diameter and no pneumoperitoneum or air/fluid levels.

• What is the most likely diagnosis?
• What is the next step?

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CASE SCENARIO ,,, A 49 year old woman presents to the emergency room complaining of a 4 week history of progressive abdominal swelling and discomfort. She has no other gastrointestinal symptoms, and she has a normal appetite and normal bowel habits. Her medical history is significant only for three pregnancies, one of which was complicated by excessive blood loss, requiring a blood transfusion. She is happily married for 20 years, exercises, does not smoke, and drinks only occasionally. On pointed questioning, however, she does admit that she was wild in her youth, and she had snorted cocaine once or twice at parties many years ago. She does not use drugs now. She was HIV negative at the time of birth of her last child.

On examination, her temperature is 100.3 F, heart rate 88 bpm, and blood pressure 94/60 mmHg. She is thin, her complexion is sallow, her sclerae are icteric, her chest is clear, and her heart rhythm is regular with no murmur. Her abdomen is distended, with mild diffuse tenderness, hypoactive bowel sounds, shifting dullness to percussion, and a fluid wave. She has no peripheral edema. laboratory studies are normal except for Na 129 mEq/L, albumin 2.8 mg/dL, total bilirubin 4 mg/dL, prothrombin time 15 seconds, hemoglobin 12 g/dL with mean call volume 102fL, and platelet count 78,000/mm3.

• What is the most likely diagnosis?
• What is your next step?

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CASE SCENARIO ,,, A 65 year old white woman is brought to the emergency room by her family for increasing confusion and lethargy over the past week. She was recently diagnosed with small cell cancer of the lung. She has not been febrile or had any other recent illnesses. She is not taking any medications. Her blood pressure is 136/86 mmHg, heart rate 84 bpm, and respiratory rate 14 breaths per minute and unlabored. She is afebrile. On examination she is an elderly appearing woman who is difficult to arouse and reacts only to painful stimuli. She is able to move her extremities without apparent motor deficits, and her deep tendon reflexes are decreased symmetrically. The remainder of her examination is normal, with a normal JVP and no extremity edema. You order some laboratory tests, which reveal the serum sodium level is 108 mmol/L, potassium 3.8 mmol/L, bicarbonate 24 mEq/L, blood urea nitrogen 5 mg/dL, and creatinine 0.5 mg/dL. Serum osmolality is 220 mOsm/kg, and urine osmolality is 400 mOsm/Kg. A CT scan of the brain shows no masses or hydrocephalus.

• What is the most likely diagnosis?
• What is your next step in therapy?
• What are the complications of therapy?

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CASE SCENARIO ,,, A 55 year old diabetic woman with end stage renal disease(ESRD),has been treated with peritoneal dialysis (prescription of four echanges,2 L exchange per day for 6 years,She is 80 kg

.The patient complains of nausea fatigue, abdominal discomfort, Medications include Erythropoetin, Calcium carbonate, water soluble vitamins. Lab studies showed hematocrite 38%, blood urea 160 mg/di, Serum creatinine 13 mg/dl, bicarbonate 14 meq/I, Calcium 10 mg/dl, Phosphate 2.3 mg/dl. Thlp most likely dlpgtnosis is:

 a) Mycobacterial peritonitis.
b) Dialysis dysequilibrium.
c) Uremia due to under dialysis,
d) Peritoneal carcinornatosis,
e) Diabetic ketoacidosis

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CASE SCENARIO ,,, A 73 year old woman presented to the ER complaining of increase breathlessness over the previous 4 days. She has felt unwell for two months and has lost 4 kg in weight. She has frequent nosebleeds, and over the past few days had coughed up small amounts of fresh blood. She noticed that she has been passing less urine in the past few days.

On examination, she is febrile (38C), centrally cyanosed and looks unwell. She has a purpuric rash over her ankle. Her pulse is 104/min regular, blood pressure 120/90. Her JVP is not raised. Her hearts sounds are normal with no added sounds. Her respiratory rate is 30 breathe/min, expansion is reduced, percussion and tactile vocal fremitus are normal but she has coarse inspiratory crackles throughout both lung fields. Her abdominal and neurological examination is normal. Investigations: Hemoglobin 10.1 g/dl, white call count 17.2 x 10^9/l, platelets 540 x 10^9/l, potassium 6.6 mmol/l, bicarbonate 8 mmol/l, creatinine 832 umol/l, albumin 32 g/l, phosphate 1.9 mmol/l, Arterial blood gases: pH 7.18, pCO2 5.1, pO2 6.4, Urinalysis: ++protein, +++blood, urine microscopy: > 100 red cells; red cell casts; no organisms, ECG: sinus tachycardia

What is the likely diagnosis?

How would you manage and investigate this patient?

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CASE SCENARIO ,,,  A 28 year old female teacher complaining of increased irritability and anxiety. Her changes in personality has been noticed by her husband and colleagues at work. She feels constantly restless and has difficulty concentrating on a subject for more than a few moments. Her increased anxiety has developed over the past three months. She  has lost 6 kg in weight despite a healthy appetite. She has also noticed an increased frequency of bowel movement. Her periods have become lighter and shorter. She feels extremely tired, sweats profusely and cannot tolerate hot weather. She has no significant illnesses previously. She is married with no children. She is a non-smoker and drinks 10 units of alcohol per week.

On examination she appears agitated and her hands are sweaty and tremulous. Her eyes appear prominent with lid retraction. Her pulse is 104, regular and blood pressure 130/70. Examination is otherwise normal. CBC with only bicarbonate of 22 mmol/l, rest in normal.

What is the most likely diagnosis? And how would you manage this patient?

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