Case Puzzlers

A 45-year-old man who was very active and could run up to 100 miles until 2 months prior to presentation started complaining of dyspnea on exertion, reduced exercise capacity, increased fatigue, and a dry cough.

A 37-year-old man with type 1 diabetes had a 2-day history of worsening nausea, vomiting, malaise, and abdominal pain that began shortly after intentionally stopping his insulin regimen.

A 55-year-old Caucasian woman with scleroderma presented to the hospital in February 2009 with severe dyspnea. She felt well until 1 week prior, when she developed fevers, chills, and an intermittent dry cough.

An 18-year-old healthy man presented to the ED with several days of sore throat and fever.

A 68–year–old man previously diagnosed with a "heart-murmur," but otherwise considered healthy, was transferred to our hospital with a 3–day history of fever, back pain and confusion.

A 64-year-old man is transferred to the ICU for acute onset of confusion, septic shock, acute renal failure and disseminated intravascular coagulation.

A 38-year-old man with a history of urethral and esophageal strictures, as well as smokeless tobacco use, was referred to the pulmonary clinic for a suspicious nodule in the right upper lobe seen on a CT scan. He had a history of oral squamous cell carcinoma stage III (T1N1M0) treated with wide local excision and bilateral neck dissection. Surgery was followed by one cycle of a planned three cycles of cisplatin complicated by severe pancytopenia requiring hospitalization. The patient subsequently received adjuvant radiation therapy to the neck. A follow-up CT scan demonstrated a suspicious nodule in the right upper lobe for which he was referred to a pulmonary medicine specialist. On exam, he has stable vital signs, including pulse oximetry. He has well-healed incisions on his neck and skin changes consistent with radiation therapy. His cardiac and lung examination results are normal. The only other noteworthy finding is that he has significant dystrophic fingernails. He states that he has had them all of his life.

A 41-year-old woman at 17 weeks gestation was referred for resting dyspnea. On physical examination, she had a faint diastolic murmur. ECG revealed mitral stenosis with dilated left atrium and a normal ejection fraction. She had two prior documented strokes and is noncompliant with her anticoagulant medication. She is not responding to the current medical management.

Clinical presentation The patient is a 76-year-old African-American man referred for evaluation of shortness of breath and cough. His shortness of breath had progressively worsened over the last 2 months. He also had a history of productive cough with clear sputum for 2 months.

After reading the Chapter, test your knowledge with questions from ACCP-SEEK Sleep Medicine, First Edition:

A 63-year-old retired radiologist was on vacation in Atlantic City. He had a mild upper respiratory tract infection approximately 1 week earlier. While in his hotel room, he noted the acute onset of orthopnea. He went to a local emergency room. In the ED, he reported orthopnea and dyspnea when bending over, but he could walk about two blocks on level ground. He denied cough, fever, wheezing, or sputum production. Review of systems was only notable for bilateral shoulder pain.