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Endocarditis with disseminated thromboembolisms and hypercoagulable state
Ten months after radical cystectomy and adjuvant chemotherapy for an anaplastic giant cell bladder cancer (pT2N2M0), a 41-year-old woman presented with a 4-week history of intermittent claudication, lower right back pain, transient monocular vision loss, and fever.Woman in a coma
A 49-year-old woman of unremarkable past health was found comatose in her car. Blood pressure was 130/70 mmHg, pulse 80 beats per minute. There was no circumstantial evidence of drug overdose. Urine toxicology tested negative. Electrocardiography (ECG) showed anterolateral ST-segment elevation (Fig. A). Head computed tomography (CT) of demonstrated no intracranial pathology. Non-sustained ventricular tachycardia developed shortly. Echocardiography revealed left ventricular dysfunction with akinesia of mid-ventricular walls but sparing basal and apical segments (Fig. B, video).Blurred vision: Hitting the bull's eye
An 18-year-old female presented with progressive blurred vision in both eyes. On evaluation, her uncorrected visual acuity was 20/400 in both eyes. Slit lamp examination revealed bilateral supero-temporal dislocated lens splitting the pupillary axis with visible stretched zonules (Fig. 1). Intraocular pressure and posterior segment evaluation were normal. Systemic examination revealed a late systolic murmur at the apex.Acute necrosis of the corpus callosum
A 58-year-old man with a history of alcohol use disorder was admitted for apathy, confusion and aphasia of abrupt onset. In addition, clinical examination revealed a tetrapyramidal syndrome. Blood analyses showed macrocytosis, mildly elevated liver transaminase levels and hypoalbuminemia. Toxicological screening for ethanol, opiates, cannabinoids, amphetamines, cocaine, and methadone were negative. A brain magnetic resonance imaging (MRI) was performed and showed bilateral cytotoxic lesions involving the splenium of the corpus callosum depicted by T2/fluid attenuated inversion recovery (FLAIR)-weighted hyperintensities (panel A) with restricted diffusion (hypersignal on b1000 diffusion-weighted sequences and hyposignal on apparent diffusion coefficient map, panels B and C respectively) (Fig. 1).A woman with purple-brown skin lesions after immunosuppressive therapy
An 80-year-old Greek woman presented to our clinic with fatigue and new-onset skin lesions around her neck, enlarging and multiplying over the previous 6 weeks. The lesions were asymptomatic but had been causing the patient considerable embarrassment. She had no fever, chills, night sweats or weight loss. Six months earlier, she had required treatment with corticosteroids and rituximab (375 mg/m2 of body-surface area per week for 4 weeks) for severe thrombocytopenia associated with autoimmune hemolytic anemia (Evans’ syndrome).A « tipical » but rare cause of neck pain
A 34-year-old man with medical history of familial deafness presented to the emergency department for an acute left cervicalgia and painful jaw for one week. He reported a context of recent physical effort because of house moving. He had already performed a cervical echography, which showed a thickening of the wall of the left common carotid artery (panel A) without disturbance of the vascular flow on Doppler (panel B). At presentation, vital parameters were normal with symmetrical blood pressure measurement, and no fever.Not always “straight ahead” – A surprising cause of acute kidney injury
A 16-year-old girl presented with a complaint of vomiting and abdominal pain, which appreared immediately following hair straightening treatment. Her medical history was remarkable for untreated cutaneous psoriasis. She denied any use of over-the-counter medications, herbal products or illicit drugs.A red herring electrocardiogram
A gentleman in his 50s presented with atypical chest pain for the last 3 months. He had no prior comorbidities. Cardiovascular system examination was unremarkable. Baseline electrocardiogram is shown in Fig. 1A. The primary care physician labelled the electrocardiogram as ST-segment elevation myocardial infarction and advised immediate coronary angiography and intervention. The electrocardiogram was reviewed by the cardiology team, and a repeat electrocardiogram was advised, shown in Fig. 1B.Dorsal pigmentation of tongue
A 56-year-old male patient with diabetes presented with black discolouration of the tongue 7 days after extraction of two mandibular molars (Fig. 1). Prophylactic oral amoxicillin 750 mg was started a day before the extraction and was continued for 4 days after extraction. Post-extraction, because of severe pain in the socket, he did not eat properly or maintain good oral hygiene. We collected a sample from the tongue lesion and performed a cytological analysis. Fragments of filiform papillae with markedly enhanced keratinisation were observed on microscopic examination of the scraped specimen.“Milking” the way to diagnosis
A 43-year-old non-smoker man presented to the emergency department with exertional dyspnoea and left pleuritic pain lasting for 3 days. He denied fever and cough and described a history of pulmonary embolism, deep venous thrombosis and multiple opportunistic infections, namely angio-invasive pulmonary aspergillosis and pulmonary and brain Nocardia sp. Infections, the brain abscess requiring surgical excision and causing squeal epilepsy. He was chronically medicated with rivaroxaban 20 mg id, Levetiracetam 500 mg bid and co-trimoxazole 960 mg bid 3 times a week.Generalized erythematous scaly rash after glucocorticoids
A 65-years-old woman with a medical history of idiopathic thrombocytopenic purpura and psoriasis in treatment with topical glucocorticoids presented with a three-month history of burning, generalized erythematous, scaly rash, and chills. A few weeks before the rash, the patient presented petechiae on her thighs due to a low platelet count (28.000 platelets per microliter), for which she started treatment with prednisone 25 mg/week. The rash was initially treated with topical ointments including clobetasol, urea, salicylic acid, ammonium lactate, and propylene glycol without improvement.Interstitial pneumonia with subpleural sparing and weight loss
A 36-years-old man from West Africa was admitted to our ED with respiratory failure and a 15 days history of fatigue and peevish cough. He reported watery diarrhea and a 30 kg weight loss in the last three months. In his clinical history, he did not make any recent trips abroad, nor did he reported any chronic disease, any contact with domestic or wild animals or any drug abuse. He received a complete vaccination course for SARS-CoV-2. On the physical examination we observed low-grade fever, bilateral diffused crackles on chest auscultation, latero-cervical and supra-clavicular lymphadenopathies and a maculopapular rash spread on the upper limbs and trunk.Malar rash with pancytopenia
A 35-year-old Japanese man presented with a four-month history of persistent flushing and persistent high fever (≥38 °C) for the past several weeks.A diabetic patient with finger gangrene
A 72-year-old male with type 2 diabetes and end-stage renal disease (ESRD) receiving hemodialysis (HD) for 10 months presented to hospital with one week of worsening pain, swelling, and bluish-black discoloration in the second and fourth right, and third left fingers. Preceding trauma to the digits had not occurred. Physical examination revealed dry gangrene in the digits (Fig. A), but no necrotic lesions in the lower limbs. An arteriovenous fistula (AVF) was created in his left forearm. Laboratory examinations showed fairly controlled diabetes (HbA1c 7.3%, post-prandial blood glucose 175 mg/dL), leukocytosis, and elevated C-reactive protein.Necrotic ulcers in an immunocompromised patient
A 68-year-old man presented to dermatology clinic with extensive ulcers for one-week duration. Patient had underlying uncontrolled Type II Diabetes Mellitus and pemphigus foliaceous. His medications were metformin 1 g twice daily, prednisolone 30 mg daily and azathioprine 50 mg daily. He denied fever, prior trauma or insect bites.An unusual cause of severe watery diarrhea
A 75-year-old man presented to the gastroenterology department with a 4-week history of severe watery diarrhea (at least 20 times a day) and appetite loss. He had been taking amlodipine 5 mg once daily for 12 years and olmesartan 20 mg once daily for 11 years because of hypertension. His vital signs were stable, and the abdominal examination was normal. He was neither anemic nor icteric. His body weight decreased by 5 kg during the last 1 month. Laboratory evaluation showed that serum creatinine level and serum uric acid level were elevated at 1.46 mg/dL (range 0.6–1.1) and 12.1 mg/dL (range 3.6–7.0), respectively.Heart failure: An autopsy case
A 78-year-old man with a history of bilateral carpal tunnel syndrome was admitted to our hospital with congestive heart failure. On physical examination a systolic ejection murmur was documented. B-type natriuretic peptide and Troponin I were elevated (8342 pg/ml and 0,2 ng/dl respectively).Persistent fever, bloody diarrhea, and skin necrosis in a young female
A 28-year-old Caucasian female presented with a two-month history of low-grade fevers, abdominal cramps, occasional bloody stools, weight loss, high C-reactive protein (234 mg/L), and with a newly-onset painful bullous skin change on the right hand (Fig. 1A). Her prior medical history included inflammatory bowel disease (IBD) successfully managed with peroral mesalazine. At the current admission, broad spectrum antibiotics (meropenem and vancomycine) were empirically started; however, the fever persisted, the blood and stool cultures were repeatedly negative, as was the skin swab.A HIV-positive subject with dermatomal and generalized vesicular skin lesions
A 58-year old man with HIV infection diagnosed in 2018 presented in July 2021 with a 7-day history of vesicular skin lesions localized to the right side of abdomen and diffuse vesicular lesions on the face, trunk, abdomen and both arms (Fig. 1A e 1B).Skin rash following amoxicillin treatment
A 26-year-old woman presented with a chief complaint of nausea for 2 days. On the previous day, she had been diagnosed with tonsilitis by her previous doctor because of fever and sore throat, and had started treatment with amoxicillin. On examination, bilateral enlarged tonsils with white spots were observed. Blood tests showed elevation of hepatic transaminase and lactate dehydrogenase levels. We suspected acute hepatitis because of her recent consumption of undercooked beef and elevation of hepatitis type A antibody.Diffuse pulmonary ill-defined centrilobular opacities: Not only bronchiolitis
metastatic pulmonary calcificationHemolytic anemia in a patient with cirrhosis: Hiding in the smear!
A 41-year-old female with alcoholic liver cirrhosis presented to the emergency department with worsening abdominal pain and progressively worsening shortness of breath for two weeks. Laboratory studies revealed a hemoglobin of 4.2 g/dL (reference range 12.0–15.5 g/dL), hematocrit 14.1% (reference range 36–44%), red cell distribution width 21.8% (reference range 12.2–16.1 g/dL), total bilirubin 6.2 mg/dL (reference range 0.1–1.0 mg/dL), indirect bilirubin 3.5 mg/dL (reference range 0.2–0.8 mg/dL).Chilblain-like acral lesions
A 70-year-old Asian female presented to the rheumatology clinic with a 5-year history of tender papules on fingers and toes aggravated under cold exposure. She also reported polyarthralgia and Raynaud phenomenon for 3 years. On examination, red painful papules were present on index fingers, middle fingers, thumbs, and toes, with central crust and ulceration (Fig. 1A-D). The toenail plates were partially or completely destroyed with hyperkeratosis of the nail bed (Fig. 1D). The extremities were cool to the touch.Vanishing tumor of the stomach
A previously healthy Japanese 36-year-old man presented to the gastroenterology department with a 2-day history of acute-onset severe epigastric pain after eating flounder sashimi. His vital signs were normal. Emergency endoscopy showed a submucosal tumor-like lesion with mild erosions in the upper body of the stomach (Fig. 1, Panel A). Further observation revealed a whitish linear worm penetrating the mucosa at the edge of the lesion (Fig. 1, Panels B and C). What is the diagnosis?Granulomatous lesions of the skin: Do not fall into the trap
A 51-year-old woman was referred to investigate skin lesions present on her backside.A man with fever and aortitis
A 54-year-old man presented with a chief complaint of fever and pain around the left clavicle. He had a primary germ cell tumor of the mediastinum and had been undergoing chemotherapy for approximately six months. To prevent myelosuppression, pegfilgrastim was administered after each chemotherapy session. Pegfilgrastim was administered 4 days before the onset of fever and pain. On examination, he had a body temperature of 38.1 °C and pain in the left arm. Laboratory findings showed elevated C-reactive protein level (19.4 mg/dL).Chest pain in a Ukrainian woman living in Italy immediately after news of homeland Russian invasion.
A 54-year-old Ukrainian woman without cardiovascular risk factors presented with left-sided chest pain. The symptom appeared as soon as she got the news from her relatives in Ukraina of the beginning of the Russian bombing on February 24th, 2022. Physical examination was negative. The ECG showed sinus rhythm with slight elevation of the ST segment in the precordial leads (Figure. A). Laboratory testing revealed an elevated high-sensitivity troponin I level (4929 ng/L), with normal renal function and Nt-proBNP levels.(Figure. B)Abdominal aortic aneurysm and gas in the kidney in a diabetes patient
A 65-year-old man was admitted to our emergency department with a 12-day history of nausea and a progressive backache, and an 8-day history of dysuria with low-grade fever. He had been diagnosed with diabetes mellitus 20 years previously, and had a history of poor glycemic control.A pretibial skin lesion in a patient with type 1 diabetes mellitus
A 17-years-old woman with type 1 diabetes mellitus known since the age of 9 was admitted in the high-dependency unit for diabetic ketoacidosis. She had a history of poor glycemic control and many previous hospitalizations. Two years earlier, she reported the appearance of a red-brown, telangiectatic and hyperpigmented patch, localized in the pretibial skin of her left leg (Fig. 1). The lesion was well-circumscribed with erythema at the periphery. Two months before a spontaneous ulceration appeared in the middle of the lesion, apparently without any trauma.Palpitations in a middle-aged male… Searching a needle in a haystack
A gentleman in his 50s presented with episodes of intermittent palpitations which were self-limiting. His symptoms were not related to exertion and had short duration with sudden onset and offset. He had no prior comorbidities and denied history of syncope. Cardiovascular system examination was unremarkable. Baseline electrocardiogram is shown in Fig. 1A. The electrocardiogram during an episode of palpitations requiring urgent hospitalization is shown in Fig. 1B. He was treated with intravenous amiodarone infusion and subsequently switched to oral anti arrhythmic medications.A diagnosis at hand
A 45-year-old man was found unconscious on the sidewalk and brought to the Emergency Department. He could not provide anamnestic information, but the hospital electronic archive revealed he was homeless and had a history of excessive alcohol consumption (250–300 g daily intake). He suffered from depressive disorder and had attempted suicide 9 years before by caustic ingestion, which led to total gastrectomy and esophagojejunal anastomosis. Physical examination revealed a Glasgow Coma Scale score of 8 with no focal neurological signs.Segmental anhidrosis and heat intolerance
A 62 year-old woman with no previous medical history presented to the Dermatology department with sweating disorders for several years. She described segmental hyperhidrosis and hyperemia while running. This excessive sweating occurred in the left hemiface, the left half of the trunk, the left upper limb and the right lower limb (Fig. 1A). This was associated with heat intolerance and previous faintness during sport. She did not describe any chest pain before faintness and the cardiac auscultation was normal.Acute abdominal pain following esophagogastroduodenoscopy
A 48-year-old man developed abdominal pain and vomiting twelve hours after esophagogastroduodenoscopy. He had lost 4.4 kg while being treated for a gluteal muscle abscess two months prior, and then underwent surgery for gastric perforation one month prior to admission. His-postoperative course was uneventful and endoscopy showed a healed benign gastric ulcer. His-past medical history included schizophrenia and poorly controlled type 1 diabetes. Prescribed medications included insulin and vonoprazan.Darier's sign
A 38-year-old Caucasian male presented with a ten-year history of back pains, dyspepsia and allergic rhinitis and conjunctivitis treated with non-steroidal antirheumatic drugs and on-demand antihystamines. During this time, slowly progressive brownish freckles and patches on the trunk and the extremities began to occur. Because the patient was an entrepreneur with a busy working schedule, he did not pursue any further medical workup. However, due to increasing back pains, he underwent regular massages, and after these treatments, the skin on the back usually became swollen, itchy and red (Fig. 1A), necessitating the use of antihystamines.Autosplenectomy
A 30-year-old woman manifested fatigue and high fever. She was diagnosed with antiphospholipid antibodies positive-systemic lupus erythematosus (SLE), but she had never demonstrated any serious organ involvements including nephritis and thrombosis, and had never received immunosuppressants. Physical examination demonstrated costovertebral tenderness and pyuria, and she was treated with cefaclor for uncomplicated pyelonephritis. After ten days, she visited our emergency room with the same manifestations and was improved equally by cefaclor.An unusual cause of colitis
An 81-year-old Japanese woman presented to the author's department with acute abdominal pain and nausea. Laboratory evaluation showed a white-cell count of 13,270 cells/mm3 (Reference range, 3500–8500) and a C-reactive protein of 2.37 mg/dL (Reference range, 0.00–0.30). Non-enhanced computed tomography (CT) revealed calcification of mesenteric veins and thickening of the wall of the ascending and transverse colon (Fig. 1, Panel A). Colonoscopy showed edematous mucosa with erosions in the right hemicolon (Fig. 1, Panel B).Multiple organ nodules or polyps
A 48-year old female presented with intermittent epigastric pain for 2 months accompanied with belching, nausea, vomiting and occasionally melena. She had endometrial polypectomy and thyroidectomy in 2018. A resection of nodules in the right lung was performed in 2019. In addition, she had a history of breast cyst. The patient had no clear family history of any cancerous disease.Multiple tumors on the pleura with pleural effusion mimicking malignant mesothelioma
A 68-year-old male presented with left chest pain and was referred to our hospital due to left-sided pleural effusion on a chest X-ray (Fig. 1 A). Initial laboratory data included a white blood cell count of 5650/μL and a C-reactive protein level of 0.36 mg/dL. CT during drainage of bloody effusion showed multiple tumors on the left chest wall and diaphragm, and residual effusion on the dorsal side, without hilar or peripheral lung lesions (Fig. 1B, C). No extrathoracic tumors were detected. Although effusion cytology was positive for malignancy, the histological type could not be determined even with cell block specimens.New onset rectal bleeding
A 36-year-old male with no significant past medical history presented to the emergency department for new onset hematochezia. Prior to arrival, the patient reported having five episodes of passing bloody stool and frank blood without associated abdominal or rectal pain, nausea, vomiting, or fever. He denied rectal trauma including anal receptive intercourse. He was not on any prescription medications. On physical examination, his vital signs were normal. His abdominal examination was unremarkable, and digital rectal examination revealed an empty rectal vault.Stuck in my head as an old song
A 61-year-old piano man was admitted to the emergency department for loss of consciousness, aphasia and Glasgow coma scale of 13 points. His past medical history included hypertension, non-insulin-dependent diabetes mellitus and occasional inhalation of cocaine.“Comb and Target signs” in abdominal CT in patients with purpura
A 56-year-old woman complained of nausea, abdominal pain, and bloody diarrhea 10 days prior to the day of consult in our institution. Her abdominal pain worsened and was accompanied by joint pain for several days, prompting a consult at our hospital. Physical examination revealed strong rebound tenderness in the right lower abdomen and the presence of multiple palpable purpuras in the lower extremities (Figure C). Laboratory test results revealed a high C-reactive protein level of 1.21 mg/dL, as well as normal renal function and urinary findings.COVID-19 vaccination and a severe pain in the neck
A 40-year-old woman developed malaise and severe anterior neck pain 12 hours after the second dose of COVID-19 mRNA vaccine (Pfizer/BioNTech). The pain peaked and plateaued at the fourth post-vaccination day. Her GP prescribed ibuprofen and azithromycin for presumed bacterial pharyngitis, with no avail. She visited our endocrine clinic 26 days post-vaccination with ongoing symptoms including bony aches, exhaustion, emotional lability, palpitations and hyperhidrosis. Upon general examination she was haemodynamically stable but with significant neck tenderness (visual acuity score = 8/10).An unusual cause of heart failure
A 59 year-old lady presents to the hospital with complaints of exertional shortness of breath for the past few months. This was associated with orthopnea and lower limb swelling. On examination, she had bibasal crepitations on chest auscultation and bipedal oedema to the ankles. She had nil significant past medical history or family history of cardiac disease. Her electrocardiogram revealed normal sinus rhythm with nil ST segment changes. B-type Natriuretic Peptide was raised at 2,430pg/ml and her chest radiograph showed cardiomegaly with signs of pleural effusion.Facial hypertrichosis, hyperpigmentation, and hepatosplenomegaly
A 51-year-old woman presented for evaluation of new-onset of facial hypertrichosis, hyperpigmentation and blistering on the back of the hands with sunlight exposure, additionally she referred change of urine to reddish coloration; previously she was being studied for anaemia and neutropenia, and received multiple blood transfusions as treatment. She has no significant medical history. Physical examination demonstrated scars in sun exposed areas, evident hypertrichosis in her cheeks, hepatosplenomegaly, and pink fluorescence of the urine with Wood's lamp illumination (WLI) (Fig. 1).The truth comes out of children's mouths
A 16 year-old patient of Hawaiian ancestry was admitted for confusion in April 2018. He had no relevant past medical history except he went to the dentist few months ago for patchy darkish pigmented macules of the oral mucosa (Fig. 1A). His mother reported that he complained of pharyngitis and diarrhoea since one week. Blood pressure, body temperature and heart rates at admission were 80/50 mm Hg, 38.3°C and 163 beats per min respectively. Oxygen saturation and glycemia were estimated to 100% room air and 3.2 mmol/L using pulse oximeter and glucometer respectively.Subarachnoid hemorrhage as the key to the diagnosis
A 70-year-old woman was admitted at the emergency department due to abdominal pain progressing over the last six hours. She had been feeling sick for the last month, with nausea and persistent fever. Initial work-up revealed mild anemia, elevated inflammatory markers and an unremarkable abdominal ultrasound. While at the emergency department, she suddenly progressed to coma, with admission to the intensive care unit. Both cranial CT scan and angiography were conducted, showing a cortical artery aneurysm surrounded by a sulcal subarachnoid hemorrhage on the left parietal convexityFig. 1.Skin lesions, weakness, and axillary adenopathies in a 44-year-old woman
A 44-year-old woman was referred to the Internal Medicine clinic with a six months history of generalized, worsening myalgia, Raynaud's phenomenon and muscular weakness. These symptoms were associated with asthenia and a weight loss of 5 Kg. Physical examination revealed a stony-hard left axillary lymphadenopathy, bilateral 3/5 quadriceps strength and hyperkeratotic skin lesions depicted in Fig. 1; the remainder of the examination, including breast examination, was normal. Blood tests showed elevated creatinphosphokinase (6363 UI/L), lactate dehydrogenase (779 UI/L), aspartate aminotransferase (156 UI/L), alanine amininotransferase (183 UI/L), and aldolase (159 UI/L); the rest of the tests were anodyne.Man with pruritic rash
A 41-year-old previously healthy man presented with a 3-day history of fevers, headache, abdominal pain, and pruritic rash. The rash began on his forehead and extended to the rest of his body. He had been taking amoxicillin, which he was prescribed at an urgent care, and applying calamine lotion with no improvement in symptoms. He did not take any medications or supplements, including steroids or other immunosuppressive therapies. He did not have recent travel, sick contacts, or tick exposure. Review of systems was negative for changes in vision, sore throat, cough, dyspnea, nausea, vomiting, diarrhea, myalgias, weakness, or dysuria.Lupus pernio: Skin manifestation of systemic disease
62-year-old woman presented to our institution with the chief complaint of slowly progressive exertional dyspnea over the preceding two years in conjunction with a cough and facial rash. Physical examination was remarkable for erythematous to violaceous nodules and plaques around eyes, over eyelids and over the nose (Fig. 1A). Complete blood count, comprehensive metabolic panel, erythrocyte sedimentation rate and C-reactive protein were unremarkable. Computerized tomography(CT) of chest Innumerable groundglass nodules again identified in bilateral lungs as well as scattered areas of tree-in-bud pattern (Fig. 1B).A febrile patient with an unusual eruption
A 45-year-old man presented to dermatology outpatient department with complaints of sudden-onset, painful, clustered, monomorphic, punched-out erosions and ulcers, distributed symmetrically in the periocular and malar area, and nose (Fig. 1). He also complained of associated fever, malaise and bilateral cervical lymphadenopathy. Additionally, multiple eczematous lesions and excoriations were present over his beard region.Itchy papular and nodular skin lesions in chronic kidney disease patient
A 65-year-old man with a history of obesity, type 2 diabetes mellitus (DMT2) for more than 10 years, stage 3b chronic kidney disease (CKD) and hypertension was admitted to our internal medicine ward for face cellulitis. He also complained of a 4-month history of moderately to severely generalized itchy skin lesions (Fig. 1) that had gradually increased in number. Clinical complaints had no correlation with time of the day or activities made. During that period, he denied use of new pharmacies and there weren't similar symptoms in family members.Pulsatile neck veins and hepatomegaly, and icterus in an elderly female
A 60-year-old male presented with complaints of deepening jaundice of 3-weeks duration. It was not accompanied by pyrexia, abdominal pain, or malaise. The patient gave a history of hot flushing. On examination, she had icterus, pedal edema, raised jugular venous pulse till the angle of the jaw with a prominent c-v wave and rapid y-descent suggestive of Lancisi's sign (panel A and video 1). Cardiac examination revealed grade 3/6 pan-systolic murmur at lower left sternal border increasing with inspiration.A young man with abdominal pain and intestinal distension
A 20-year old man of Balkan descent presented to the emergency department with abdominal pain and constipation of several days‘ duration. On clinical examination, he was afebrile and normotensive. The abdomen was distended with reduced bowel sounds. Laboratory investigations were significant for hyponatraemia (129 mmol/l) and elevated aminotransferases in the double digits; inflammatory markers were normal. Abdominal ultrasound was unrevealing as to a specific cause but meteorism was noted. Cortisol response to an adrenocorticotrophic hormone stimulation test was normal.An old-age farmer with chronic dyspnea
A 94-year-old man, known case of chronic lymphocytic leukemia and chronic lung disease, presented to the Emergency Department with aggravation of his chronic dyspnea and non-productive cough since about 2 weeks prior to hospitalization. He had no complaint of fever or chest pain. At the time of hospital admission, the patient was tachypneic (respiratory rate of 22 breaths/minute), tachycardic (pulse rate of 110 beats/minute), normotensive, and afebrile. His-physical examination was also significant for a decreased breath sound in lower part of right lung field – with a dull percussion -, fine bibasilar crackles, mild and diffuse wheeze, and bilateral lower extremities pitting edema up to the level of calves.Woman with seizures
A 66-year-old woman with a history of hyperlipidemia presented to the emergency department after a epileptic seizure episode for nearly 1 min. She had a normal temperature, pulse rate was 77 beats/min, blood pressure was 85/40 mm Hg, and pulse oximetry was 92% on room air.She felt chest tightness when exercise for 1 week. Laboratory test was significant for cardiac troponin I level of 0.12 ng/ml, B-type natriuretic peptide lever of 866.96 pg/ml, D-dimer lever of 2520 ng/ml. She had a head computerized tomography of no cerebral hemorrhage or infarction.An elderly man with a locked jaw
An 86-year-old man with diabetes mellitus presented to our hospital with a 3-day history of difficulty opening his mouth. He reported that he had injured his right index finger while farming 15 days ago, resulting in a 1-cm-diameter red bruise. He had not received any diphtheria, tetanus, and pertussis vaccinations. He was afebrile and alert, presenting no mental status changes. Physical examination revealed a stiff neck, trismus, and spasmodic laughter (Fig. 1). Blood tests showed leukocytosis, high creatinine kinase, and high glucose levels.Spontaneous pneumothorax in a patient with skin lesions
A 23- year- old man, presented to the emergency department with sudden dyspnea, without another symptom. On examination he had hypoxemia, and abolished breath sounds in the right lung. Skin evaluation revealed the presence of multiple small rounded papules of white coloration with follicular accentuation, located in the upper dorsal region of the thorax (Fig. 1A). Computed tomography (CT) of the chest showed right spontaneous pneumothorax and multiple thin-walled cysts in both lungs (Fig. 1B).Painless ulcer on the dorsal aspect of hand
A previously healthy 47-year-old man presented a 3-month history of progressive proliferative plaque and ulcer on the dorsal aspect of the right hand. Initially, the patient was bitten by an irritable woman savagely during a dispute on a bus. Bleeding from the wound was stopped by local treatment. Six weeks later, the lesion expanded despite the prescription of irregular oral antibiotics in community hospitals. The patient is heterosexual and denied extramarital sex. On physical examination, the ulcer was brownish-red and 7 to 9 cm in diameter.Recurrent facial palsy and fissured tongue
A 28-year old Chinese man presented with right facial paralysis for 8 days. He felt that for first 3-days, his right face was swollen that subsided after starting oral valaciclovir and prednisolone by his general practitioner. He did not have any pain or swelling of the parotid gland and denied any ear symptom. He had developed right facial paralysis 7-years ago and left facial paralysis 2-years ago, which recovered considerably within a month on both occasions. He did not have any cardiovascular risk factors or immunocompromised state.A case of suprapubic pain
A 71-year-old male with a past medical history of prostate cancer s/p radiation treatment seven years ago. He presented to the emergency department with acute onset pain in the suprapubic region. He denied associated symptoms of nausea, vomiting, urinary urgency, urinary frequency and dysuria. He was afebrile and hemodynamically stable on presentation. On abdominal examination he had suprapubic tenderness. Initial basic lab work including CBC, BMP and lactate levels were normal. Urinalysis was negative for any signs of infection.No more than meets the eye
A 33-year old Ivorian woman was admitted for fever and thrombocytopenia. She had been previously treated in France by tocilizumab then anti TNF-α for rheumatoid arthritis since 7 and 2 years respectively. She lost weight three months ago, whereas her last trip to Ivory Coast was three years ago. Physical examination was unremarkable except a hectic fever. Complete Blood count revealed hypochromic microcytic anaemia (6.1 g/dL) and profound thrombocytopenia (11 000/mm3), Serum C reactive protein and ferritin values were 81 mg/L and 636 ng/mL respectively.Atypical cause of dysphagia
A 27-years-old male presented with progressively worsening dysphagia for four years. The dysphagia was worse for solids, and for the past three months, the patient had restricted his diet to liquids and pureed foods. He had also developed some hoarseness in his voice during this time. Past medical history was significant for gastroesophageal reflux disease, hypertension and hyperlipidemia. Physical examination was unremarkable.When and how did the air come in?
An 84-year-old man with cognitive dysfunction was taken to the emergency room because of a change in consciousness. He came in with a Glasgow Coma Scale (GCS) score of E4V4M5. According to his family, this was not his usual state. It was difficult to hear the medical history from him, and there were few specific complaints. Upon physical examination, there were no abnormalities on the body surface and no complaints of pain. Head CT was performed to investigate the cause (Fig. 1 A and B).The long toenail sign in older adults
A 78 year old male attended a geriatric medicine outpatient clinic accompanied by his son. He described a history of falls, memory impairment and difficulty completing activities of daily living including cutting toenails. He also reported bilateral foot pain. Comprehensive geriatric and frailty assessments were performed. His son described how he was assisting his father with grocery shopping and household cleaning but was not aware his father had developed difficulties in maintaining foot care.Atypical cause of episodic abdominal pain and unintentional weight loss
A 23-year-old female with past medical history of generalized anxiety disorder and migraine presents to the clinic with unintentional weight loss of approximately 20 lbs and chronic episodic abdominal pain associated with nausea and vomiting for 6-8 weeks. Physical examination and initial blood workup were unremarkable.A forgotten disease in Japan
A 67-year-old woman with acute onset of fever, disorientation, and confusion was transferred to our emergency department. Physical findings revealed neck stiffness, left dominant tremulous arms with cogwheel rigidity of her extremities. Computed tomography showed mild atrophy without cerebral bleedings. Magnetic resonance imaging (MRI) with fluid-attenuated inversion recovery (FLAIR) sequence was shown in Figure (Fig. 1. on day 2, and Fig. 2. on day 5). What is the diagnosis?A man with arthralgias and skin lesions
A healthy 43-year-old man presented to the Emergency Department with a one-week history of fever, low back pain and arthralgias mainly localized in the right knee. Physical examination revealed painful swelling of the left hand and lower limb (Fig. 1A), non-tender haemorrhagic macular lesions on the soles (Fig. 1B) and signs of right knee arthritis (Fig. 1C). Laboratory tests showed aspecific neutrophilic leukocytosis. A computed tomography of the lumbar region demonstrated a paravertebral mass located at L4-L5 level, which was consistent with spondylodiscitis associated with soft tissue involvement.Family rash
A healty 35-year-old woman suddenly developed a papular rash with linear disposition, involving predominantly her arms. She had no history of allergies and did not take any medication; moreover she did not complain about any other symptom.Concomitant pulmonary and rib lesions in a 44-year-old male nonsmoker
A 44-year-old male nonsmoker presented to the respiratory department with progressive left chest pain for 20 days. He had previously been healthy with normal immunity. He had no cough, fever, breathlessness, or sputum production. Physical examination revealed local tenderness on the left 10th posterior rib. Chest computed tomography showed bilateral multiple pulmonary nodules, thin-walled and thick-walled cavities and left 10th rib lytic lesion (Fig. 1a). Whole-body bone scan showed a central defect with the peripheral uptake of the “donut”-like change sign on the left 10th rib (Fig. 1b).“High absorption area in the pelvis”
A 42-year-old man presented to our emergency room with epigastric pain. He had undergone a barium examination 6 weeks previously for gastric cancer screening. He was apyrexial. Physical examination revealed slight tenderness in the epigastric region and McBurney's point. However, there were no signs of peritoneal irritation such as percussion tenderness. A plain radiographic study of the abdomen revealed high-absorption areas in the pelvis (Fig. 1A). Abdominal computed tomography revealed metal artifact-like findings in the appendix (Fig. 1B and Fig. 1C).Bilateral foot drop and cherry skin lesion
A 34-year-old woman with no previous medical history presented with bilateral lower limbs weakness and numbness for three months. It was progressively worsening that she required wheelchair for ambulation in the last month. Neurological examination revealed bilateral foot drop with mild pedal oedema. There was symmetrical distal muscle weakness of the lower limbs with ankle dorsiflexion of 1/5, plantar flexion of 3/5, knee and hip flexion and extension of 4/5. Deep tendon reflexes were absent at the ankles and normal at the knees.Spontaneous discoloration of the finger in a 67-year-old woman
A 67-year-old woman presented to our clinic because she had developed spontaneous pain and purple discoloration of the fourth finger of her right hand that had started the previous day. She had experienced similar episodes previously, which were not related to cold exposure and had resolved spontaneously. She had no history of trauma and was not taking any medication. On examination, the finger showed mild swelling and a reddish-purple hematoma centered around the proximal interphalangeal joint (Fig. 1).Chronic urticaria with inflammation
A 67-year-old man presented with a 15-year history of chronic urticaria. It was distributed symmetrically on the limb trunk (Fig. 1A and B) without pruritus. No fever or joint pain or headache is observed. He showed no signs of angioedema. He was referred to our hospital for treatment of chronic urticaria. An antihistamine was ineffective. He was diagnosed with mild sensorineural hearing loss. He had no family history of autoinflammatory diseases.Atypical chest pain with precordial T wave inversions
A 74-year-old woman with a prior history of coronary artery disease presented to the emergency department with intermittent, burning epigastric pain. Five months prior, she had a stress echocardiogram that showed no signs of ischemia. On presentation, her cardiac exam was normal, chest auscultation revealed wheezes, and the chest wall was tender. Her chest pain resolved on admission. A complete blood count, comprehensive metabolic panel, and serial troponin levels were normal. Serial 12-lead electrocardiograms (ECGs) demonstrated dynamic T wave inversions in the precordial leads, most notably in leads V2-V3 (Figure 1A-B).Bright liver: a surprise discovery
A 69-year-old woman with hypothyroidism, alcoholic liver disease, coronary artery disease, ventricular arrhythmia requiring placement of an implantable cardioverter defibrillator, and end-stage renal disease on hemodialysis presented for evaluation of chronic anemia (hemoglobin level of 7-8 g/dL) with transfusion dependence. Notable medications include aspirin, amiodarone, warfarin, levothyroxine, and lansoprazole. Her vital signs were normal. Physical and neurological examinations yielded no abnormal findings.What ‘s the link between otological signs and oral contraception?
A 48-year-old woman presented chronic headache and serous otitis with feeling of fullness of the right ear. She had no medical or surgery history. ENT and clinical neurological examination revealed no other anomaly. She didn't take any treatment except Nomegestrol Acetate (NA) contraception for 15 years. A Cerebral Magnetic Resonance Imaging (MRI) was finally performed.A middle-aged woman with acute onset of fever, altered mental status, and movement disorder
A 60-year-old woman was admitted in the emergency room with acute onset of fever, altered mental status, and movement disorder. The patient had well-controlled type 2 diabetes mellitus with hemoglobin A1c up to 6.0%. In addition, neither steroids nor immunosuppressive agents had been taken. Brain magnetic resonance imaging (MRI) was shown in Fig. 1. What is the diagnosis?Paroxysmal Atrial Fibrillation on Flecainide Therapy
Flecainide pill-in-the-pocket therapy is a pharmacologic treatment option for patients with infrequent episodes of symptomatic atrial fibrillation. We report a case of wide complex tachycardia due to atrial flutter with 1:1 atrioventricular conduction in a patient who took pill-in-the-pocket flecainide without concomitant atrioventricular nodalblockade.Bilateral hilar opacities
A 20-year-old male was admitted to the emergency department with a 1-week history of fever, right pleuritic chest pain and aggravating sporadic hemoptoic cough.Chest pain in a middle-aged smoker with heart failure and missing lung
A 45-year-old man presented with sharp, left-sided chest pain of one-hour duration that radiated to the right chest and back, and started two hours after snorting cocaine. He was an active smoker and his medical history included pulmonary embolism on anticoagulation, heart failure with reduced ejection fraction of 9% with an implantable cardioverter-defibrillator, and cocaine use disorder. Vital signs were normal, except for a respiratory rate of 20 breaths per minute. Laboratory examinations were unremarkable, and an electrocardiogram was unchanged when compared to previous ones.A middle-aged woman with numbness and weakness of the extremities
A 45-year-old woman presented to the neurology department with numbness and weakness of extremities, which had progressed during 3 months. The patient had tingling sensation in the left neck. Although muscle atrophy was not observed, manual muscle test revealed grade 4 weakness in bilateral deltoid muscles, right upper and left lower limbs. The patient had normal deep tendon reflex, and Babinski reflex was negative bilaterally. Laboratory blood tests showed no abnormalities. Spinal fluid examination revealed a slightly increased protein level of 56 mg/dL (normal range: 10–45 mg/dL) and no white blood cells.Disturbance of consciousness after postpartum hemorrhage
A 37-year-old woman with postpartum hemorrhage was transferred by ambulance to our hospital for emergency treatment. On arrival massive hemorrhage continued, and she developed tachycardia (130 beats/min), hypotension (60/30 mm Hg) and tachypnea (50 /min). She underwent blood transfusion and emergent hysterectomy, and her vital signs became stable. The estimated total bleeding volume was approximately 8 L, and pathological examination revealed placenta accreta. Five days later, she had disturbance of consciousness.Anterior neck mass that appeared after a common cold
A 62-year-old man experienced a common cold for 7 days. He presented to the clinic with a 2-day history of anterior neck pain and swelling. His body temperature was 37.4°C, and a soft, well-defined mass was palpated in the midline near the hyoid bone (Fig. 1A). Slight erythema and tenderness were noted at the same site. A contrast-enhanced neck computed tomography (CT) was performed (Fig. 1B).McGinn-White pattern
A 52-year-old man presented to the emergency department with a 2-month history of worsening dyspnea which intensified during the last 3 days. On physical examination, his blood pressure was 119/68 mm Hg, his pulse rate was 99 beats per minute, and his respiratory rate was normal. An electrocardiographic study (Fig. 1A) and computed tomographic (CT) angiography of his chest (Fig. 1B) were performed at the time of hospital admission.A spontaneous hematoma in a healthy young woman
A 40-year-old woman presented herself with a large hematoma of her left lower limb which appeared spontaneously three weeks prior to her visit. The hematoma was responsible for a symptomatic anemia, so she was transfused with two packed red blood cells. Her past medical history was marked only by a depressive syndrome. She was currently taking neither medication nor drugs.Beware of the air when diabetes is there
A 73-year-old woman with past history of dementia and type 2 diabetes mellitus (DM) was admitted to the emergency department because of drowsiness and hyperglycaemia. The capillary blood glucose was 335 mg/dL and capillary ketone levels were in the normal range. Physical examination was unremarkable. During hospital stay, she developed fever (38.9°C). The laboratory tests revealed leucocytosis (white blood cell count of 16.25 × 109/L) with neutrophilia and a C-reactive protein of 3.61mg/dL. The liver function panel revealed cytolysis and cholestasis.Bone pain, splenomegaly and microcytic anemia in a young woman
A 23 years old female patient presented to clinical hematology consultation with asthenia and mild bilateral femoral pain. She has a history of anemia without clear etiology during her childhood. Physical examination showed pallor without icterus and a splenomegaly, 14 cm below the left costal margin. There was no hepatomegaly and no peripheral lymphadenopathy. Complete blood count revealed a microcytic anemia (hemoglobin, 8 g/dL; reference range 12 to 16, median corpuscular volume, 72 fL) and thrombocytopenia (platelet count, 70,000 per microliter; reference range 140,000 to 400,000).Goosebumps and angioid streaks in a patient with cerebrovascular disease.
A 55-year-old man was referred to the dermatology department for a long history of asymptomatic lesions on the skin of his neck and axillae. He had a remarkable history of recurrent ischemic strokes and cerebral small vessel disease with progressive cognitive decline during the last 10 years. He was also a regular smoker and he suffered from diabetes mellitus, hyperlipidemia, obesity, hypertension and hypertensive heart disease. Physical examination revealed small, yellowish papules looking like “goosebumps” in the lateral aspects of the neck (Fig. 1A) and a thickened and hanging skin in both axillae (Fig. 1B).Amlodipine-induced gingival hypertrophy
A 57-year-old male patient who was guided by a dentist, presented with gingival swelling to the department of hematology (Fig. 1A). He had been suffering from increasing gingival enlargement for two months in maxillary and mandibulary teeth and also gingival bleeding while tooth brushing or eating. He had a history of hypertension, which he had been treating with oral amlodipine (10 mg once daily) for the past one year and type 2 diabetes mellitus, which he had been treating with oral metphormin.A great masquerader disease…
A 64-year-old-man, with history of hypertension, dyslipidemia, serous chorioretinopathy and past-smoking history (15 pack-years) presented with asthenia and weight loss (6 kg in 6 months). His-physical examination was unremarkable and biological tests showed inflammation (CRP 20 mg/L). A retroperitoneal fibrosis was diagnosed on CT-scan with a left pulmonary nodule and mediastinal lymphadenopathy (Fig 1. A, B), these lesions being hypermetabolic on PET-scan. A lung nodule biopsy showed no malignant cells, but fibrosis associated with a lymphocytic infiltration.Multiple cutaneous lesions and pulmonary cysts
A 50-year-old woman presented with multiple cutaneous lesions that had been present for many years (Figure 1a and 1b) similar to other family members. Her past history was significant for seronegative arthritis, juvenile rheumatoid arthritis, iron deficiency anaemia, menorrhagia and cholecystectomy. She had never smoked. Family history was significant for thyroid cancer in her mother. Computed Tomography (CT) scan of her thorax demonstrated multiple intraparenchymal pulmonary cysts and subpleural bullae bilaterally (Figure 1c and 1d).Multiple facial prominences of benign origin
An 18-year-old girl sought medical advice for an asymptomatic prominence of the right malar region evolving for two years because of cosmetic concern. Her medical history was relevant for Salmonella infection during a trip in Africa. The patient did not consume alcohol or use illicit drugs. She reported no history of trauma, fever, blurred vision or headache. On examination she was healthy. A prominence of the left lateral jaw was observed with normal overlying skin, limited mobility, and not painful to palpation.A YOUNG LADY WITH CHEST PAIN
28-year-old woman with no significant past medical history presented with acute onset of sub-sternal chest pain at work. It was “pinching” type and got worse on deep breathing, coughing, leaning forward and drinking water. The pain was radiating to the back. She did not have any similar previous episodes. No recent strenuous workout including swimming, valsalva or other physical activity or trauma was reported. Her blood pressure was 135/80 mmHg; pulse 53/minute; respiratory rate 16/minute; temperature 98.2°F and oxygen saturation was 98% on room air.Sudden onset headache, dizziness, unilateral facial numbness, and speech disturbance
A 48-year-old woman presented to the emergency department with acute onset of headache, dizziness, right facial numbness, and difficulty of swallowing and speech. She was not a smoker and consumed alcohol occasionally, and there was no surgical or other medical history. On admission, her blood pressure was 114/78 mm Hg, pulse rate was 72 beats per minute, and room air arterial oxygen saturation by pulse oximetry was 100%. Laboratory tests showed no abnormalities. Physical examination revealed paresthesia of right side of face and left lower extremity and paralysis of right vocal cord, but with no other neurological findings such as consciousness disturbance, cerebellar ataxia, double vision, and hemiparesis.A 44-year-old man with cough, arthralgia, and fever
A 44-year- old man presented with dry cough, diffuse joint pain, fevers, and night sweats for one month and poor appetite and weight loss for three months. Physical examination showed hepatosplenomegaly. A chest computed tomogram (Panel A and B) showed diffuse miliary nodules. Sputum for acid fast bacilli was negative. Testing for HIV-1 was positive with a high viral load and a low CD4 count of 4/µL. Bronchoscopy with bronchoalveolar lavage was performed. Gomori methenamine-silver stain of the bronchoalveolar lavage specimen showed intracellular yeasts within macrophages with narrow-based budding (Panel C).Woman with sore throat, fever and abdominal pain
A 32-year-old woman, presented to the Emergency Department (ED) with a 15-day fever, and a sore throat recently associated with a growing abdominal pain. At admission in the ED, the patient had normal vital parameters and her history showed no underlying comorbidities. On physical examination, abdominal tenderness was observed with an important (8/10) left upper quadrant pain associated with a palpable splenomegaly. The rest of the clinical examination was normal except for a mild odynophagia. Six days before the ED admission, the patient had consulted her General Practitioner who prescribed a complete blood test.Joint pain, black urine… and a heart murmur
A 64-year-old man, with history of hypertension and hypercholesterolemia, presented with chronic polyarthralgias and backache. He had brown-colored deposits in sclera and blueish pigmentation in helix of both ears (Fig. 1A, B). X-ray examination revealed prominent calcification of intervertebral discs (Fig. 1C). In addition, the patient reported episodes of black urine in his childhood. The color of a urine sample was initially normal, however, it turned blackish after several hours (Fig. 1D). 24-hour urine sample analysis showed high levels of homogentisic acid (HGA) (73,152 mg; normal range 0–10 mg).Beware of the dog
A 24-years old male complained new-onset urinary retention during a return flight from a 1-month trip to Thailand, needed to be urgently catheterized. His past medical history was unremarkable. He is a seasonal worker in vineyards in France and left for Thailand in early September as a volunteer in a kennel. During his journey, he remains free of any symptom but for two isolated episode of diarrhea, upon the arrival in a dog-house. After the landing, he was promptly admitted to our Infectious Diseases Unit: neurological examination reported a symmetrical flaccid paralysis of the lower limbs with hyporeflexia, hypoesthesia, a thoracic sensory level on T4-T5 with both urinary and feces retention.The unintended consequences of a bowl of soup
A 33-year-old Romanian woman presented with a one day history of “cola-coloured” urine with associated fevers. She reported generalised malaise, arthralgia and reduced appetite for 24 h. The patient had a history of beta-thalassemia trait. She was not taking any regularly prescribed or over-the-counter medications and had no known allergies. Scleral icterus was noted on examination. There was no pathological lymphadenopathy or organomegaly. Her laboratory investigations were as follows; haemoglobin 3.6 g/dL, mean corpuscular volume 99.2 fl, platelets 219 × 109/L, white cell count 13.4 × 109/L, reticulocytes 351 × 109/L, direct antiglobulin test – negative, total bilirubin 88 umol/L, C-reactive protein 100 mg/L, lactate dehydrogenase 1250 u/L (upper limit 240 u/L) and haptoglobin 0.41 umol/L.
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