1. Intermittent fevers (sốt cơn), chills and headache in a 26-year-old male

HISTORY OF PRESENT ILLNESS

A 26-year-old male visiting the United States from India pre-

sented to the ED complaining of several days of intermittent

fevers, shaking (rung, lắc) chills and headaches. He denied (không có) shortness ofbreath or cough, neck stiffness, abdominal pain or dysuria/dis'juəriə/ tiểu khó .

He reported mild nausea, diarrhea and anorexia /ænou'reksiə/ chán ăn, as well as a sore throat and decreased oral intake during this time. He

was seen two days previously in an outside clinic, diagnosed

with streptococcal pharyngitis (viêm họng) and started on oral amoxicillin-

clavulanate. His symptoms had not improved. The patient

arrived from India five days prior to presentation in the ED.

He denied chronicmedical problems and took nomedications.

He denied tobacco, alcohol or illicit /i'lisit/ trái phép drugs, and was traveling

on business. According to the patient, his immunizations/,imju:nai'zeiʃns/ miễn dịch  were up to date.

PHYSICAL EXAMINATION

GENERAL APPEARANCE: The patient was awake and alert /ə'lə:t/ tỉnh táo

 ,although he appeared ill and dehydrated.

VITAL SIGNS

Temperature 104.4◦F (40.2◦C)

Pulse 123 beats/minute

Blood pressure 115/64 mmHg

Respirations 22 breaths/minute

Oxygen saturation 99% on room air

HEENT: PERRL, EOMI, sclera anicteric, oropharynx dry,

without oral lesions or exudates.

NECK: Supple, no meningeal/mi'nindʤiəl/ thuộc màng não signs, no cervical lymphadeno-pathy.

CARDIOVASCULAR: Tachycardic rate, regular rhythm without

rubs, murmurs or gallops.

LUNGS: Clear to auscultation bilaterally.

ABDOMEN: Soft, nontender (không chướng), nondistended (không sưng), without hepato- orsplenomegaly.

EXTREMITIES: No clubbing (ngón tay dùi trống), cyanosis or edema.

SKIN: Warm and moist, no rashes (nổi mẩn).

NEUROLOGIC: Nonfocal (không có dấu hiệu chỉ điểm).

A peripheral intravenous line was placed, and blood was

drawn and sent for cultures and laboratory testing. Intra-

venous fluids were administered (2 liters of normal saline)

along with acetaminophen orally for the fever and morphine

sulfate IV for the headache. A 12-lead ECG demonstrated

sinus tachycardia, rate 120, without acute ST-T wave changes.

Laboratory tests revealed a leukocyte count of 4.5 K/μL

(normal 3.5–12.5 K/μL) with 12% bands (presence of bands

abnormal), 53% neutrophils, 16% lymphocytes, 19% mono-

cytes, and hematocrit of 41% (normal 39–51%) with 77

K/μL platelets (normal 140–400 K/μL). The serum glucose

was slightly elevated at 170 mg/dL (normal 60–159 mg/dL),

whereas the serum sodium was slightly decreased at 131 mEq/

L (normal 137–145 mEq/L). The remainder of the electrolytes

were within normal limits. Liver function tests revealed an

AST of 72 U/L (normal 17–59 U/L), ALT of 81 U/L (normal

11–66 U/L) and total bilirubin of 1.7 mg/dL (normal 0.2–1.3

mg/dL). A chest radiograph and noncontrast CT of the brain

were performed (Figures 89.1 and 89.2, respectively).

A lumbar puncture to evaluate for possible meningitis

was performed. Examination of the cerebrospinal fluid (CSF)

revealed 1 white blood cell (WBC) and 1 red blood cell (RBC)

per μL, slight elevation in CSF glucose at 86 mg/dL (normal

40–73 mg/dL) and normal CSF protein. Gram stain of the CSF

revealed neither organisms nor white blood cells.

What is your diagnosis?

2. Abdominal pain and dysuria in a 16-year-old male

HISTORY OF PRESENT ILLNESS

A16-year-oldmale presented to the EDcomplaining of supra-

pubic pain radiating to the right testicle, dysuria, urgency and

frequency for eight days. The patient was seen one week

prior to his ED visit by his primary care provider (PCP), at

which time he described the previous complaints as well as

subjective fevers. At that time, the patient’s temperature was

99.2◦ F (37.3◦

C). He was noted to be well appearing and in no

acute discomfort. The abdominal examination revealed mild

suprapubic tenderness to palpation without the presence of

rebound or guarding, no costovertebral angle tenderness

(CVAT) was noted and his genitourinary (GU) examination

was normal. A urinalysis was negative for infection and the

patient was diagnosed with a viral syndrome.

Three days prior to his ED presentation, the patient re-

ported a temperature of 103◦F (39.4◦C) and severe supra-

pubic pain. The following day, the intensity of his pain dimin-

ished somewhat and his fever resolved. In the ED, the patient

continued to complain of crampy abdominal pain at a level of

6 (on a scale of 0 to 10), with associated dysuria, urgency and

frequency.He denied nausea, vomiting, diarrhea, constipation

or penile discharge, and was tolerating oral liquids.

PHYSICAL EXAMINATION

GENERAL APPEARANCE: The patient was lying supine on the

gurney, appeared comfortable and in no acute discomfort.

VITAL SIGNS

Temperature 98.7◦F (37.1◦C)

Pulse 88 beats/minute

Blood pressure 120/80 mmHg

Respirations 20 breaths/minute

Oxygen saturation 100% on room air

HEENT: Unremarkable.

NECK: Supple.

CARDIOVASCULAR: Regular rate and rhythm without rubs,

murmurs or gallops.

LUNGS: Clear to auscultation bilaterally.

ABDOMEN: Soft, nondistended; suprapubic, periumbilical and

right lower quadrant tenderness to palpation without rebound

or guarding (maximal point of tenderness over suprapubic

area). No CVAT.

RECTAL: Normal tone, brown stool, hemoccult negative.

GENITOURINARY: Circumcised, no penile discharge, testes de-

scended bilaterally, no testicular swelling or tenderness, no

hernias.

EXTREMITIES: No clubbing, cyanosis or edema.

NEUROLOGIC: Nonfocal.

A peripheral intravenous line was placed, and blood was

drawn and sent for laboratory testing. Laboratory tests re-

vealed a leukocyte count of 16 K/μL (normal 3.5–12.5 K/μL)

with 84% neutrophils (normal 50–70%); electrolytes, creati-

nine, glucose and urinalysis were within normal limits.

What is your diagnosis?

3. Assault with stab wounds to a 16-year-old male

HISTORY OF PRESENT ILLNESS

A 16-year-old male was brought to the ED by his mother after

complaining of (kể lại, trình bày) abdominal pain.Upon (ở trên) further questioning, the teenager admitted that he had been stabbed several times with a knife the prior evening, once in the abdomen and twice in

the back. In the ED, he reported diffuse abdominal pain, most

prominent in the left lower quadrant. He denied fevers, chills,

nausea, vomiting, diarrhea or constipation. Other than the

stab wounds, he denied additional injuries. His tetanus vac-

cination was current.

PHYSICAL EXAMINATION

GENERAL APPEARANCE: The patient was a well-developed,

obese male, and in no acute discomfort.

VITAL SIGNS

Temperature 98.5◦F(37◦C)

Pulse 96 beats/minute

Blood pressure 100/67 mmHg

Respirations 16 breaths/minute

Oxygen saturation 98% on room air

HEENT: Atraumatic, normocephalic, PERRL, EOMI.

NECK: Supple, no midline tenderness.

CARDIOVASCULAR: Regular rate and rhythm without rubs,

murmurs or gallops.

LUNGS: Clear to auscultation bilaterally.

ABDOMEN: A 2-cm vertical stab wound to left mid-abdominal

wall (panel A, Figure 54.1) without bleeding, erythema or pus.

The abdomen was nondistended, with diffuse tenderness to

palpation, most prominent in the left mid-abdomen around

the stab wound; no rebound, guarding or crepitus was noted;

bowel sounds were hypoactive.

RECTAL: Normal tone; soft, brown stool, hemoccult negative.

EXTREMITIES: No clubbing, cyanosis or edema; no deformities

or wounds.

LEFT FLANK: A 1.5-cm wound in the mid-left flank and a 2-cm

wound in the superior left flank consistent with stab wounds

were noted, without bleeding, erythema or pus (panel B, Fig-

ure 54.1);mild tenderness around the stab wounds was present

without crepitus.

SKIN: No other stab wounds were appreciated on thorough

skin exam with the patient completely disrobed.

NEUROLOGIC: Nonfocal.

A peripheral intravenous line was placed and blood was

drawn and sent for laboratory testing. A 500-mL bolus of

normal saline IV was administered, as well as morphine sul-

fate for pain and cefazolin 1 gm IV for infection prophylaxis.

The wounds were anesthetized with lidocaine, irrigated with

normal saline and packed with sterile gauze. Laboratory tests

including a complete blood count, electrolytes, creatinine, glu-

cose, liver function tests and coagulation studies were within

normal limits. A chest radiograph (Figure 54.2) and CT scan

of the abdomen and pelvis with oral and IV contrast (Figure

54.3) were obtained.

What is your diagnosis?