The 2 nd module, 6 ENG 9

A 40-year-old woman presented with uncontrolled hypertension and
weakness since May 2001. On examination, her blood pressure was
144/107 mmHg. A 12-lead electrocardiogram (ECG) reading showed
left ventricular hypertrophy. 

Haematological investigation demonstrated that the patient had a
metabolic alkalosis with bicarbonate of 26.4 mmol/l. Her initial potassium
level was low, i.e. 1.3 mmol/l (normal is 3.3 - 5.3 mmol/l) and initial
sodium was high, i.e. 149 mmol/l (normal is 135 - 147 mmol/l). Her
renin level was <4.5 mIU/l (low), aldosterone was 2 234 pmol/l (high)

WHAT IS YOUR PROBABLY Dx?

A 77-year-old Korean woman came to the outpatient clinic of the department of family medicine, Seoul National University, Seoul, Korea, presenting with chest pain that started the day before. She had a medical history of hypertension and had been on medication (losartan and aspirin) for 5 years. The day before, at about 7 PM she suddenly felt a strong chest pain of numerical rating scale (NRS) 8-10 in the substernal area. 

She described the character of the pain as oppressive without radiating pain. This excruciating pain lasted for about 10 minutes combined with a doomed feeling, diaphoresis, and difficulty in taking deep breaths

Electrocardiogram (EKG) was immediately taken which showed normal sinus rhythm with nonspecific ST deviation. Laboratory findings were as follows: creatine kinase (CK) 129 IU/L, CK-myocardial band 3.0 IU/L, troponin I 0.03 ng/mL, C-reactive protein 0.59 mg/dL, white blood cell 8,900/µL, hemoglobin 11.4 g/dL.

Imaging results show aortic dissection

WHICH IS EXCLUDE PRESENCE OF MI 

WHAT IS YOUR SUSPECTION?

An 18-year-old man was involved in a high-speed frontal collision in which his motorcycle struck a bull cart. Approximately 30 minutes later, he was admitted to the emergency room. At presentation, he was confused, violent, and complaining of thoracic and abdominal pain. He developed hypotension with a systolic blood pressure ranging between 60 mmHg and 80 mmHg, with a pulse rate of 120 bpm and a respiratory rate of 35 breaths per minute. Bruise marks were found on his right flank as well as on his chest. His extremities were clammy with marked peripheral hypoperfusion. Notably, his external jugular veins were distended. Cardiovascular examination revealed auscultated and muffled dual heart sounds with no cardiac murmur. Plain X-ray suggested a widened mediastinum. After chest and abdominal Computed Tomography (CT) scans were finished, he underwent circulatory collapse. The CT scans revealed massive pericardial effusion and confirmed cardiac tamponade.

CHOOSE BECK'S TRIAD SYMPTOMS

A 34-year-old Hispanic male presents with the chief complaint of
chest pain. The patient had been well until 10 days prior to
admission, when he developed a severe sore throat accompanied by
fever, rigors, and diffuse myalgias. There was no associated cough.
Three days later, he visited his primary care physician at an outside
facility and was prescribed penicillin 500 mg twice daily for
presumed streptococcal pharyngitis. Five days later, he presented to
the emergency room of an outside hospital and stopped his
antibiotics after a throat culture there was negative for beta-
hemolytic strep. The following morning, the patient awoke in the
middle of the night with severe left-sided chest pain and presented
again to his local emergency room. The patient described a
sensation of left-sided chest pressure which became worse when
lying down. the patient was febrile to 38.5 C.  The patient underwent cardiac catheterization on the first day of admission. The coronary arteries were angiographically normal. Laboratory testing was remarkable for a leukocyte count of 27.6 and a troponin of 12.7. A serum anti-streptolysin-O antibody was sent
and returned as 1541 IU (normal < 200). The erythrocyte sedimentation rate was 48 

UNDERLINE ONE MOJOR AND TWO MINOR CRITERIA FOR ACUTE RHEUMATIC FEVER

INDICATE LEVEL OF POTASSIUM IN CONN*S DISEASE