Matfin G

Arthralgias following dilation and curettage

A 36-year-old woman presented to the emergency department with right hip pain of one weeks duration. An x-ray of the hip was unremarkable. She was diagnosed with trochanteric bursitis, given ibuprofen (800 mg tid) and crutches, and sent home. The next day, continual pain and progressive functional impairment prompted her to see an orthopedist. He concurred with the initial diagnosis and administered a corticosteroid injection into the right trochanteric bursa. Propoxyphene (65 mg q4h prn) was added to her medical regimen, and she was again sent home. Pain developed in the right sacroiliac area the next day. Within 24 hours, the right shoulder and right sternoclavicular joint were also involved, and the patient began having subjective fever and chilliness. She returned to the orthopedist and was immediately referred to a rheumatologist who ordered blood cultures and admitted her to the hospital.

A CONFUSED MAN WITH RAPID RESPIRATION

A 71-year-old man presented with incoherent, slurred speech, auditory hallucinations, and tachypnea. According to the neighbor who called for emergency medical service, the man had appeared to be in good health the day before. On admission, his blood pressure was normal.

An inflamed elbow after an insect sting.

A 63-year-old man presented with fever and a painfully swollen right elbow and forearm. He had been stung by a yellow jacket two weeks earlier and had since found it increasingly difficult to bend his arm.

COMPLICATION AFTER ARTERIAL BYPASS GRAFTING

A 57-year-old man experienced sudden onset of pleuritic chest pain and respiratory distress 10 days after undergoing four-vessel coronary artery bypass grafting (CABG). The surgery was performed after cardiac catheterization had shown right coronary artery dominance and the presence of lesions occluding 40% of the mid right coronary artery, 20% of the left main coronary artery, and 99% of the lower left anterior descending artery and its first diagonal branch. The patient had initially presented with acute dyspnea following an episode of crushing, nonradiating pain in the left chest and was diagnosed as having a non-Q-wave myocardial infarction after cardiac enzyme testing. His hospital course before and immediately after CABG was uneventful. The first sign of difficulty was detected one week after surgery, on day 17. An echocardiogram showed a small pericardial effusion, moderate to severe concentric thickening of the left ventricle, a left ventricular ejection fraction of 0.60 (normal, 0.67 +/- 0.08), normal valves, and normal segmental wall motion. The pleural chest pains began two days later, on day 19.

A man with vague rheumatic complaints.

A 52-year-old man presented with a four-month history of malaise, low-grade fever, decreased appetite, and a 20-pound weight loss. He complained of joint pain and swelling, proximal muscle weakness, exertional dyspnea, and a dry cough. He also noted that his fingers had turned white and then blue when chilled and red when rewarmed. He had not had pleuritic chest pain, dysphagia, dry eyes or mouth, rash, or skin photosensitivity.

A Woman with Sudden Paralysis

A 37-year-old Hispanic woman complained of having awakened with a tingling sensation, followed by sudden weakness, in both legs. A month earlier, she had experienced heart palpitations but had not had chest pain or dyspnea. She had lost 10 lb in the last two months despite an increased appetite and no polyuria, polydipsia, vomiting, or diarrhea.

A DAZED AND DISORIENTED MAN FOUND BY THE ROADSIDE

An obviously obtunded 25-year-old man was found sitting alone on the roadside by his van. A passing motorist called paramedics who brought him to the hospital. He did not respond to intravenous thiamine, glucose, and naloxone given en route.

A Man with Palpable Purpuric Hand Lesions

A 75-year-old man with seronegative rheumatoid arthritis presented with a three-day history of low-grade fever, new arthralgias, mouth sores, and bilateral cutaneous hand lesions. He had not had hand trauma.

A Man with Periscapular Pain of Unexpected Origin

A 64-year-old man presented with constant, dull pain associated with a large mass in the left periscapular area. He had had difficulty sleeping on his back since the pain began a month earlier. He had no history of trauma, insect bite, exposure to toxins, arthritis, or other joint disease. Despite a normal diet and appetite, he had lost 10 1b in the last four months.

MASSIVE HEMOPTYSIS IN A WOMAN WITH SEIZURES

A 53-year-old woman presented with a productive cough, fever, chills, and night sweats of one months duration. She reported having had lightly blood-streaked sputum initially but then experiencing massive hemoptysis (> 200 mL/2 hr). Since the onset of symptoms, she had had malaise, body aches, and a 27-lb weight loss. For the last two weeks, she had also had increasing shortness of breath and pleuritic chest pain.