A 56-year-old man develops acute swelling of his left lower leg. He says that he was at work when he first noticed that his leg felt swollen. He has had multiple previous episodes of swelling in both his left and right legs over the past year. An ultrasound is performed and reveals a superficial vein thrombosis of his lower calf. He is started on anticoagulation.
Which of the following tests would most likely be elevated in this patient?
CA 19–9. This patient has signs of recurrent superficial thrombophlebitis, a condition that is associated with underlying malignancies (specifically, adenocarcinomas of the pancreas and lung). CA 19–9 is a marker that may be elevated in cancers of the pancreas, bile duct, gall bladder, or stomach. While it is most useful in the assessment of response to treatment, it can be expected to be elevated in individuals with pancreatic cancer.
(A) CA-125 is a tumor marker specific for ovarian cancer that may be used in diagnosis and assessment of treatment response. (B) α-fetoprotein may be elevated in liver cancers and germ cell tumors. It is useful in the diagnosis of hepatocellular carcinoma and the staging of germ cell tumors. (C) β-hCG is a marker of choriocarcinoma and testicular cancer. It is most useful in the staging of cancers and may be prognostic for individual response to treatment. (E) CEA is a marker of colorectal and breast cancers. It can be used to assess colorectal cancer spread and breast cancer recurrence. Calcitonin is elevated in medullary thyroid cancer and may be used in diagnosis. It may be monitored to assess efficacy of treatment or to identify recurrence. PSA is often elevated in prostate cancer. It may be useful in diagnosis, determining individual response to treatment, and identifying recurrence of disease.
A 52-year-old woman presents with severe abdominal pain for the last 8 hours. She describes the pain as sharp and localized to her upper abdomen. The pain radiates to her back and she has vomited three times. The patient notes that she has been hospitalized several times in the past with similar complaints. She has a blood pressure of 140/80 mmHg, pulse of 108/min, temperature of 36.6°C, and respiratory rate of 18 breaths per minute. Physical examination demonstrates tenderness to palpation in the epigastric area.
Which of the following is the next step in the diagnosis of this patient’s condition?
Serum lipase and liver function tests. This patient is presenting with signs and symptoms consistent with acute pancreatitis (upper abdominal pain radiating to the back). Given that these symptoms are nonspecific and could indicate other abdominal pathology, diagnosis must be confirmed with serum amylase and lipase (more specific) levels. Liver function tests, including an alkaline phosphatase level, should be ordered as well to determine if there are gallstones or common bile duct obstruction (a cause of pancreatitis).
A 36-year-old man presents to the hospital with fever and leg swelling. His right lower extremity has a large area of erythema and swelling, and there is purulent drainage from a small area on the leg. He is admitted to the hospital and begins treatment with IV antibiotics. He suddenly develops flushing and pruritus of his face, chest, and upper extremities.
What should be done next?
Slow down the infusion rate of the antibiotic. This patient has cellulitis concerning for MRSA given the purulent drainage. Vancomycin is an appropriate treatment, and a well-known side effect of rapid vancomycin administration is red man syndrome, which is represented by the findings seen in this patient. The rate of administration should be slowed down and the antibiotic should be given over 60 minutes. (A, B) The vancomycin does not need to be stopped, and this sudden presentation is too fast for the infection to spread, so adding an additional antibiotic is not worthwhile. (C) Surgical debridement is necessary for necrotizing fasciitis, which would have signs of necrosis and crepitus on examination. (E) Severe red man syndrome may mimic anaphylaxis, but it would present with vital sign changes and angioedema (which are not mentioned in the vignette).
A 37-year-old woman is brought in to the psychiatric Emergency Department after being found running partially clothed down a major roadway. Vitals on intake reveal a temperature of 39.8°C, a blood pressure of 158/61 mmHg, a heart rate of 144 beats per minute, and a respiratory rate of 23 breaths per minute. The patient vomits after vitals are collected. The psychiatry attending immediately orders a thyroid function test and sends the patient to the medical emergency room.
After arrival in the ER, what is the best next step in management?
Administer propranolol, propylthiouracil (PTU), and hydrocortisone. This patient is exhibiting symptoms of thyroid storm, which is a life-threatening disorder that requires immediate control of heart rate (with a β-blocker), inhibition of thyroid hormone synthesis (with a thionamide), and reduction of T4 to T3 conversion (with a glucocorticoid). (A, E) Methimazole or corticosteroids are insufficient treatments of thyroid storm, as β-blockers are needed to control the patient’s tachycardia. (B) Iodine is used acutely in the treatment of thyroid storm but is given 1 hour after thionamide administration. (C) Thyroidectomy can be used in patients unable to receive thionamides; however, β-blockers and glucocorticoids must be given first.
A 23-year-old woman presents to her primary care physician complaining of fever and pain in her wrists and fingers. She has also noted several painless “bumps” on her skin. She is sexually active with multiple partners and her last menstrual period ended 5 days ago. She does not endorse any vaginal pain or discharge. Physical examination reveals bilateral tenderness of her wrists and several interphalangeal joints as well as several lesions on her hands and forearms (Figure below). Ocular examination is benign.
Which of the following is the next best step in management?
Two sets of blood cultures. The patient most likely has disseminated gonococcal disease. (E) However, Neisseria meningitidis and Staphylococcus aureus can mimic this presentation and should be excluded by blood culture prior to administration of antibiotics. Disseminated gonococcus typically presents as either a triad of dermatitis (hemorrhagic vesiculopustular lesions), tenosynovitis, and arthralgia without arthritis or purulent arthritis without skin lesions. (C) This patient has the former presentation; therefore a synovial fluid culture would be low yield. (B) Pregnancy is a risk factor for disseminated gonorrhea and should be excluded in all patients without recent menstruation (this patient’s menstrual period ended 5 days ago). (D) Hepatitis B, which causes hepatocellular damage, can present with polyarthritis and tenosynovitis but is more likely to be associated with an urticarial rash.
Click to expand