This is a continuation of Case 3, Part A.
Go through each successive part of the case. At the end of each part, quickly answer the question about your top diagnosis and the next diagnostic step that you think will give you the diagnosis (not necessarily the next step that you would do in real life). Don’t need to spend too much time thinking about these questions—you will review them at the end.
Parts 1-7
Recap of the Initial Assessment:
HPI: 55yo man with DM and HTN presents with 2 days of nausea, emesis, and loose stool. Just arrived back from El Salvador 5 days ago. “Poor historian.” Also endorsing URI-type symptoms 2 weeks ago and vertigo.
VITALS: T 36.4, HR 101, BP 163/110, RR 23, SpO2 93% on RA. GENERAL: Appears ill, mod distress. LUNGS: Clear to auscultation without appreciable crackles. HEART: Tachycardic. No murmur or edema. ABDOM: TTP of RUQ with +Murphy’s sign. NEURO: No focal deficit.
LABS: WBC 10.3, K 3.2→5.7, Cr 1.7→1.5, Gluc 243→323, Lipase 65, Lactate 2.9→4.0, tBili 1.6→2.1. βOH-butyr: 1.42
US RUQ: Gallbladder wall thickening, no gallstones.
CT A/P: Gallbladder wall edema. No bil dil. Small ascites. Trace pleural effusion and mild pulm edema.
CONSULT: Surgery: “findings consistent with acute cholecystitis… lab findings consistent with early, progressing DKA”… recommend admission to Medicine.
TREATMENTS: IVF x 6L, Zosyn, NPH + Regular insulin.
Part 8
Starting from scratch…
HPI: 3 weeks of progressive nonproductive cough and dyspnea followed by fatigue, nausea, vomiting, and vertigo in the last few days. Denied abdominal pain or chest pain. He had a sore throat 2 weeks and was taking a prescribed antibiotic for this.
GENERAL: Mild discomfort associated with complaint of vertigo. Mild increase work of breathing with minimal movement in bed.
CV: RRR, no murmurs/rubs/gallops.
PULM: Crackles in the lower half of lung fields, worse on right.
ABDOM: soft, nontender, normoactive
SKIN: Cold at feet. Trace to 1+ edema limited to lower legs. No clubbing/cyanosis. No jaundice.
What is your top diagnosis?
What is the next diagnostic step?
Part 9
Reviewing prior studies…
EKG: Sinus rhythm. LVH with repolarization abnormality. Left atrial enlargement.
CXR: Borderline cardiomegaly.
CT A/P: Gallbladder wall edema. No bil dil. Small ascites. Trace pleural effusion and mild pulm edema.
What is your top diagnosis?
What is the next step that would lead to the diagnosis?
What diagnostic lab test would confirm your diagnosis (something that might result soon enough to confirm your suspicion)?
Part 10
LABS:
A1c 8.6, TSH 1.090
ESR 2, CRP 6.9
Trop 0.019, BNP 2368
HIV negative.
Viral hepatitis panel negative.
What is your top diagnosis?
What is the next diagnostic step?
Part 11
Echo: Systolic function is severely reduced. The estimated ejection fraction is less than 20%… There is a small (7 mm x 5mm), round, independently mobile, pedunculated hyperechoic echodensity at the left ventricular inferoapex, most consistent with thrombus versus less likely a mass or mural vegetation/endocarditis.
What is the diagnosis?
What is the next step?
Part 12
While on therapeutic heparin, the patient sustains a fall in the hospital…
CT Brain: Large approximately 6 cm hypodense region involving the right and left cerebellum… with mass effect and effacement of the 4th ventricle with associated dilatation of the lateral and 3rd ventricles.
MRI Brain: Infarctions involving the right inferior cerebellum, posterior vermis, superior medial left cerebellum and left occipital lobe… most consistent with subacute infarctions, likely of embolic etiology
What is the final diagnosis?
Now that you have finished the case, go back to the beginning, review your answers, and determine what cognitive processes led you to each answer.