Clinical Challenges

Figure 1.   Case The patient is a 65-year-old man with symptoms of epigastric pain over the last 2 hours, with some dyspnea and a “clammy feeling.” He has a history of GERD and has used both an oral antacid and omeprazole within the past hours without relief. Upon exam, you find: General: Alert and oriented. Skin cool and moist Lungs: CTAB Cardiovascular: Regular rate and rhythm without f/r/g Abdomen: Soft and nontender without rigidity, …

The patient is a 57-year-old man who reports to urgent care complaining of right-sided pain in his ribs when taking deep breaths. He reports that he worked out at his health club that morning before work, but denies any pain at the time or potential cause of injury related to that. Rather, he said the pain began suddenly a couple of hours later while he was at work. View the images taken and consider what …

The patient is a 13-year-old boy who complains of pain in his right hip and groin after playing soccer. His mother says she didn’t see what happened, but reports that she looked up from a magazine she was reading to see him limping suddenly. View the image taken and consider what the diagnosis and next steps would be. Resolution of the case is described on the next page.

A 17-year-old girl presents to urgent care complaining of easy bruising, especially on her legs. She couldn’t recall having any injuries, even minor bumps, that might have caused the red and purple ecchymoses that had appeared. She insisted no one else had caused her harm. She also complained of headache and nausea. A high school student, she was about to complete her final exams and was concerned she would have bruises on her legs during …

The patient is a 78-year-old man who says he has felt dizzy for several hours. He denies chest pain, shortness of breath, or diaphoresis. Upon exam, you find: General: Alert and oriented; breathing comfortably Lungs: Clear bilaterally Cardiovascular: RRR without m/r/g Abdomen: Soft and nontender, no pulsatile mass Extremities: No pain or swelling, pulses normal and equal in all 4 extremities   Review the ECG and consider what your diagnosis and next steps would be. …

The patients is an obese 46-year-old man who complains of a painful skin lesion located between folds of skin that were touching each other. He reports looking in the mirror at home and seeing the area was very red and erythematous. He also says sometimes it feels like a burning sensation on his skin. This was most evident after being outside in the hot, humid weather. View the image taken and consider what your diagnosis …

The patient is a 6-year-old boy who was brought to your urgent care center by his parents with pain in his right leg. They explain that he while playing with friends he tried to jump from one side of a concrete retaining wall to the other—and coming up short. View the images taken and consider what the diagnosis and next steps would be. Resolution of the case is described on the next page.  

The patient is a 72-year-old woman who presents with 2 hours of chest pain with associated diaphoresis. She has a remote history of breast cancer. No leg pain or swelling or history of pulmonary embolism. On exam, you find her stated weight of 313 pounds is correct. In addition: General: Alert and oriented X 3, ambulatory Lungs: Clear to auscultation Cardiovascular: RRR without m/r/g, distant heart sounds Abdomen: Soft and NT without r/r/g Ext: Normal …

The patients is an 88-year-old woman with 3 weeks of dizziness but no complaints of chest pain/discomfort, shortness of breath, focal neurological signs, or diaphoresis. An ECG is performed by staff prior to clinician evaluation. Upon exam, you find: General: Alert and oriented X 3, ambulatory Lungs: Clear to auscultation Cardiovascular: RRR without m/r/g Abdomen: Soft and NT without r/r/g Extremities: Normal Review the ECG and consider what your diagnosis and next steps would be. …