A 20-year-old college student presents to the urgent care office complaining of a sore throat, mild cough, and runny nose for the past 2 days. The patient is diagnosed with an upper respiratory tract infection and he is offered symptomatic treatments. As he is leaving the office, he complains of a several-day history of exquisite penile tenderness that has since resolved. He denies any other associated symptoms but does endorse sexual activity with occasional condom use. Genitourinary examination demonstrates a normal penile shaft without evidence of lesions, erythema, or discharge from the meatus. There is mildly tender inguinal lymphadenopathy.
What is the most likely etiology?
Herpes Simplex Virus, type 2. A history of painful genitalia in an adolescent or young adult with a normal genitourinary physical examination is most suggestive of genital herpes infection. Classically, HSV-2 infection presents with multiple painful fluid-filled vesicles with an erythematous base that eventually burst and crust over; however, many patients do not present until the ulcers have fully healed and many patients may not notice the lesions themselves. By the time patients present to a physician, the physical examination may be benign. (A) HPV presents with multiple nonpainful verrucous lesions. (B, D, and Chlamydia trachomatis) These infections often present with urethral discharge. (C) This patient is at risk for HIV, but does not have any symptoms of acute retroviral syndrome. (Trichomonas vaginalis) Trichomonas presents in women with vaginal discharge. (Haemophilus ducreyi) Evidence of tender inguinal lymphadenopathy is found in chancroid (Haemophilus ducreyi), but this infection is exceedingly rare in the United States and mildly tender lymphadenopathy is not an unusual finding in patients with genital herpes. (Escherichia coli ) causes UTIs and is not an STI. (Conversion disorder) Always rule out medical conditions before making psychiatric diagnoses.
A 24-year-old woman is brought in by ambulance to the Emergency Department following a motor vehicle accident. She is complaining of right flank and abdominal pain. Physical examination is notable for a large ecchymosis over the right flank. A urinalysis is remarkable for 38 RBCs per high-power field.
What is the most likely site of injury?
Kidney. Hematuria on urinalysis localizes the injury to the genitourinary tract, and this patient likely has a renal hematoma given the right flank pain and ecchymosis on physical examination. (B, C) Ureters are highly protected during trauma, and a bladder injury would present with suprapubic pain and peritoneal signs. (D) Liver injuries do not present with hematuria. (E) If this were a male, a urethral tear would also be possible from rapid deceleration.
A 49-year-old woman with a history of colorectal cancer is brought to the Emergency Department with chest pain. She is found to be tachycardic and tachypneic. An ECG is normal. Upon questioning, she states that she remains in bed all day. CT angiography reveals that she has a pulmonary embolism. She is started on low-molecular-weight heparin and is admitted. Three days later, her laboratory values are drawn.
On admission, her platelet count was 180,000/mm3 . A serotonin release assay is sent and returns positive.
What is the best next step in management?
Switch to IV argatroban. This patient likely has heparin-induced thrombocytopenia, which is an immune-mediated response to unfractionated or low-molecular-weight heparin. The best option is to discontinue the low-molecularweight heparin and switch to an alternative anticoagulant such as argatroban. (A) A platelet count of 60,000/mm3 is not an indication for transfusion. (B) The risk of heparin-induced thrombocytopenia is much lower with low-molecular-weight heparin than unfractionated heparin, so switching to unfractionated heparin is a poor choice. (D) Clopidogrel and aspirin are antiplatelet medications and are not appropriate for treating a pulmonary embolism. (E) When this complication is recognized, the heparin product should be discontinued immediately.
An 80-year-old woman with a history of atrial fibrillation, dementia, and frequent falls is admitted to the hospital for a UTI. She has no history of stroke. The family is at the bedside and is requesting clarification on her medication requirements, as they are her primary caregivers.
What is the proper anticoagulation regimen for this patient?
Aspirin only. It is important to be familiar with the CHADS2 scoring system for anticoagulation in atrial fibrillation. An 80-yearold with a-fib and no other risk factors would have a score of 1, which may be treated with warfarin or aspirin. (C, D) Aspirin alone is the better option since her frequent falls give her an increased risk of bleeding. (A) It is important to continue anticoagulation unless the patient is actively bleeding. (E) Heparin is used as an anticoagulant bridge until the effect of warfarin becomes therapeutic.
A 36-year-old man presents with a severe headache that began a few hours ago. He has no prior history of headaches but does have a prior history of “kidney cysts.” His wife meets him in the Emergency Department and says that his uncle experienced something similar to this a few years ago. A CT scan shows signs of subarachnoid hemorrhage. Further imaging reveals a berry aneurysm. Neurosurgery performs an endovascular coiling procedure and the patient returns home a few days later. One week after discharge, the patient’s wife brings him back because of increased sleepiness and confusion. On examination, his temperature is 37°C, blood pressure is 135/86 mmHg, pulse is 85/min, and respiratory rate is 14 breaths per minute. His neurologic examination is normal, and his laboratory values are shown below.
What is the most likely explanation for this patient’s current state?
Cerebral salt-wasting. This patient is presenting with symptomatic hyponatremia after a recent neurosurgical procedure for management of a subarachnoid hemorrhage. Cerebral salt-wasting is associated with subarachnoid hemorrhage and classically presents a few days after neurosurgical procedures. While the exact mechanism is unclear, it may be similar to the syndrome of inappropriate ADH (SIADH) in that it leads to a net loss of sodium in the urine.
(A) While recurrent bleeding is a possibility in this patient, this would present with symptoms similar to his first episode and would likely be more rapid in onset. (B) This patient has no history of psychiatric disorders, thus psychogenic polydipsia is an unlikely diagnosis. (C) Meningitis would not fully explain the patient’s profound hyponatremia. In addition, he is afebrile without leukocytosis. (D) Brain stem herniation may lead to dysregulation of breathing and other autonomic processes and often progresses to death. This has a much more rapid onset and progression in addition to neurologic signs on examination.
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