Puzzle of a patient | Figure 1

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83 y.o. male

PMH: CHF, new dx COPD, chronic a-fib, HTN (controlled with medication), on coumadin, AV replacement, stroke this past winter

C/o increased blurry vision, echoing in head, dizziness, fatigue

Pt is jaundice and has had multiple CHF exacerbations in the last two months

Neurology-cleared pt, suggested echoing dizziness and visual worsening due to possible inner ear infection which PCP chose not to treat pt for

Cardiology-increased Lasix to 80mg BID and ruled out low BP r/t medication as cause of dizziness

Gastroenterology-believe jaundice is due to hyperbilirubinemia

Pt had previous cholecystectomy, liver ultrasound negative, recent elevated LFTs but previously normal, low platelet count, mass appeared on ultrasound of pancreas but did not appear on MRI, has not had head CT recently, negative for hepatitis

? Possible causes of echoing, dizziness, increased blurry vision as well as cause of jaundice and why

Pt's quality of life has completely changed and he continues to get weaker and more fatigued

Would appreciate any ideas or direction to guide patient. Thank you

36 yo male

History: Type 1 DM, R MCA stroke in 2017, juvenile myoclonic epilepsy (on lamotrigine and topiramate) presented in DKA 2/2 missed medications due to increased sleeping.

Over the past year, pt has had almost daily episodes of blurred vision, dizziness, slurred speech, and an upbeating nystagmus that lasts about twenty minutes.

Also noted dysdiadochokinesia and dilated pupils during the episode.

No focal deficits. Pt oriented and able to speak and follow commands. HDS.

After resolution pt is extremely fatigued for 10+ hours. Some nausea and vomiting. No tinnitus or room spinning.

EEG unremarkable. MRI negative. TSH, ammonia, CK, renal, CBC WNL. Pt denies all infectious symptoms. UDS negative.

During one episode, lactate elevated to 3.7 but has not happened during subsequent episodes. My hospital epileptologist has signed off and said not a seizure.

Starting to wonder about autoimmune encephalitis or something like that? Considering an LP. Syphilis pending.

Please help this very confused PGY2 figure out what’s happening with this poor guy before I’m forced to discharge him and continue this cycle of having episodes, missing insulin, and presenting in DKA.

78 Y/o male

History: Trauma to head. Several healed subdural hematomas. Shunt was placed approximately 4 years ago. Has had chronic headaches for years.

Has been to several disciplines to correct headaches, but only explanation is inflammation. Recently, headaches increased to constant debilitating pain.

C/O pain in right eye and extends down the neck. Shunt was checked for proper placement and functioning as should.

Is having orthostatic hypotension and is falling. Has had two recent concussions.

Also has CHF. AML in remission.

Could this be a result of too much brain trauma? Anything else we can check?

A 52-year-old man

Presented with a 20-minute history of chest pain radiating to the left shoulder and neck, associated with dyspnea and diaphoresis.

He had a history of hypertension, long-term smoking, and a sedentary lifestyle. On physical examination, bibasilar crackles were noted on lung auscultation.

An electrocardiogram (ECG) was performed in the primary care setting, and the patient was promptly referred to the emergency department.

A 28-year-old woman

Presented with a 3-day history of intense pruritus over the lower back.

She reported no recent travel or exposure to new environments. She cares for a small kennel with approximately eight dogs rescued from the streets.

Physical examination revealed multiple small vesicles, some clustered and others scattered, predominantly involving the lumbar region and the left gluteal area.

A 4-month-old male infant

Presented with skin lesions localized to the chin for the past 3 days.

Physical examination revealed multiple small pustules with surrounding inflammatory signs on the chin, along with a few scattered papules on the chest.

Patient in late teens

Presenting after a collapse, no chest pain, no previous cardiac history, no history of sudden death in family.

Are there any features in this EKG that would warrant further work-up, or is this just a pediatric EKG?