A 48-year-old man from Mexico presents for follow-up after recently being hospitalized for chest pain. The pain was pleuritic and relieved by leaning forward, and the cause was determined to be TB. He had no pulmonary symptoms, began treatment, and was discharged. Several months later, he complains of leg swelling and abdominal pain. His vital signs are within normal limits. He has jugular venous distention with pitting edema of the lower extremities. His lungs are clear to auscultation. He undergoes cardiac catheterization, and the pressure tracings are shown in Figure below.
What is the correct diagnosis?
Constrictive pericarditis. This diagnosis should be considered in patients that previously experienced acute pericarditis (pleuritic chest pain relieved by leaning forward), especially when TB is the culprit. The findings of right heart failure (distended neck veins, leg swelling) without left heart failure (clear lungs) fits the diagnosis, although there may be some degree of left ventricular dysfunction (but not as severe as right ventricular dysfunction). The square-root sign (asterisk in figure) on cardiac catheterization is highly suggestive and is caused by a rapid increase in pressure at the onset of diastole with a subsequent plateau due to equalization of right ventricular and left ventricular end diastolic pressure. (A) This process is caused by adhesions of the two pericardial layers and fibrosis causing a rigid pericardium, not by reactivation of TB. (B) The anti-TB medications have important toxicities, but they do not cause right heart failure. (C) Pulmonary hypertension can cause right heart failure; however, there is no historical clues that explain why this patient would have this diagnosis; the recent diagnosis of TB pericarditis makes constrictive pericarditis much more likely.
A 70-year-old woman presents with complaints of a change in her voice. She first noticed hoarseness several weeks ago, which has progressively worsened. She has a longstanding history of Hashimoto thyroiditis, for which she takes levothyroxine. She is otherwise healthy. Physical examination reveals a diffusely enlarged thyroid.
What is the next appropriate step in management?
Fine needle aspiration biopsy. Patients with a longstanding history of Hashimoto thyroiditis are at a 60×-increased risk of lymphoma of the thyroid, which is most often non-Hodgkin lymphoma. Although thyroid lymphoma is rare (1% to 2% of thyroid malignancies), the association with longstanding Hashimoto thyroiditis is significant. Patients often present with the symptoms of a rapidly enlarging neck mass. A fine needle aspiration biopsy will confirm the diagnosis, along with differentiating the mass from other types of thyroid cancer. (A, B, C, E) The absence of other symptoms decreases the likelihood of an endocrine process, and it is important to rule out cancer given the patient’s history of Hashimoto thyroiditis.
A previously healthy 64-year-old woman presents with bright red blood per rectum and dizziness. She reports that the bleeding started approximately 7 hours ago and has never occurred before. The bleeding is painless. Laboratory values reveal a hemoglobin of 7.9 g/dL.
Which of the following is the most likely diagnosis?
Diverticulosis. This patient is presenting with a massive lower GI bleed, which is indicated by bright red blood per rectum, as opposed to melena, which is pitch-black stool indicative of an upper GI bleed. The most common cause of massive and painless bright red blood per rectum is diverticulosis. Other causes include angiodysplasia, which may be associated with aortic stenosis (a result of shearing of von Willebrand factor). Diverticulosis is treated with a diet rich in fiber. (A) Diverticulitis presents with abdominal pain and fever and does not typically have significant rectal bleeding. (C) Colon cancer is a common cause of lower GI bleeding, but there are no other clues that this is the diagnosis (no previous symptoms of stool changes, weight loss, abdominal pain, etc.). (D) It would be unusual for inflammatory bowel disease to present at this age.
A 55-year-old man with a 50 pack-year smoking history presents to the Emergency Department with complaints of subjective fever, cough, dyspnea, and right-sided pleuritic chest pain. The symptoms began 1 week ago and have worsened over the last 4 days. On physical examination, he has decreased breath sounds, dullness to percussion, egophony, and decreased tactile fremitus over the right lung base. An upright chest x-ray reveals a consolidation in the right lower lobe and a pleural effusion with 2 cm of fluid; the right lateral decubitus view shows evidence of loculation. A thoracentesis is performed and the pleural fluid is analyzed. Empiric antibiotics are started. Gram stain of the fluid, culture of the fluid, and two sets of blood cultures are pending.
Which of the following pleural fluid analyses are most consistent with this patient’s diagnosis?
Leukocyte count of 5,000/mm3 (80% neutrophils, 18% lymphocytes, 2% macrophages), pH 6.98, LDH 2,000 U/L, glucose 40 mg/dL. This patient has symptoms (fever, cough, dyspnea, and pleuritic chest pain) and signs (decreased breath sounds, dullness to percussion, and egophony) that are consistent with community-acquired pneumonia. Decreased tactile fremitus supports the radiographic findings of parapneumonic effusion complicating the pneumonia. Parapneumonic effusions resulting from infection such as pneumonia are typically exudative. An LDH value >two-thirds the upper limit of normal is one of the Light criteria. (B) A tuberculous exudative effusion would have a lymphocyte predominance. (C) Elevated triglycerides in the pleural effusion is consistent with a chylothorax. (D) Transudative effusions are commonly seen with congestive heart failure, nephrotic syndrome, or cirrhosis.
A 60-year-old man with a history of diabetes mellitus, hypertension, and hyperlipidemia presents to the primary care clinic with complaints of bilateral hand tremor which began 4 years ago but has been worse in the last year. He states that the tremor gets worse when he tries to eat or write. He notes that both his mother and his brother had a similar tremor. He does not drink alcohol, he smokes 1 pack of cigarettes daily, and he denies any recreational drug use. His medications include metformin, lisinopril, and atorvastatin. On examination he has a mild tremor in both upper extremities that is evoked when he holds his arms outstretched. There is no tremor while the patient is sitting at rest. There is no vocal tremor. Gait examination is normal.
What is the best treatment for this patient’s tremor?
Propranolol. This patient has essential tremor as evidenced by its exacerbation with intention (worse with writing and eating) and when maintaining a posture on examination. Essential tremor usually has an autosomal dominant inheritance, supported by a family history of the same tremor in the patient’s mother and brother. Propranolol is the first-line treatment. (B) Carbidopa–levodopa is a treatment for Parkinson disease, which features a resting, but not intentional tremor. (C) Donepezil is a central-acting acetylcholinesterase inhibitor used in the treatment of Alzheimer disease. (D) Phenobarbital is a barbiturate and has had conflicting outcomes for essential tremor, thus it is not first line. (E) Memantine is an NMDA receptor antagonist used in the treatment of Alzheimer disease.
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