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Case Records of the Massachusetts General Hospital
Case 18-2003 — A 15-Year-Old Girl with Pain in the Left Leg and Back, Pruritus, and Thoracic Lymphadenopathy
Presentation of Case. A 15-year-old girl was admitted to the hospital because of pain in the left leg and back, pruritus, thoracic lymphadenopathy, and multiple pulmonary nodules. The patient had been well until 11 months earlier, when she began to be awakened during the night by pain in the left…
Case Records of the Massachusetts General Hospital
Case 19-2003 — A Five-Day-Old Girl with Leukocytosis and a Worsening Rash from Birth
Presentation of Case. A five-day-old girl was admitted to the hospital because of a worsening rash from birth and leukocytosis with blasts. The infant was delivered at 40 weeks' gestation by a 24-year-old woman (gravida 2, para 2), who had immigrated from Central America to the United States two…
Case Records of the Massachusetts General Hospital
Case 20-2003 — A Nine-Year-Old Girl with Hepatosplenomegaly and Pain in the Thigh
Presentation of Case. A nine-year-old girl was admitted to the hospital because of hepatosplenomegaly and pain in the thigh. The patient had been well until three years earlier, when she began to have frequent episodes of epistaxis. Two years before admission, mild abdominal distention developed.…
Clinical Problem-Solving
A Gut Feeling
Foreword. In this Journal feature, information about a real patient is presented in stages (boldface type) to an expert clinician, who responds to the information, sharing his or her reasoning with the reader (regular type). The authors' commentary follows. Stage. A 79-year-old man was referred to…
Case Records of the Massachusetts General Hospital
Case 21-2003 — A 72-Year-Old Man with Repetitive Strokes in the Posterior Circulation
Presentation of Case. A 72-year-old, right-handed man was admitted to the hospital because of recurrent neurologic symptoms. The patient had been well until 10 days earlier, when he briefly had numbness of the right side of the mouth and tongue. That evening, he had slurred speech and a hyponasal…
Case Records of the Massachusetts General Hospital
Case 22-2003 — A 22-Year-Old Man with Chills and Fever after a Stay in South America
Presentation of Case. A 22-year-old man was examined in the clinic because of fever, chills, and thrombocytopenia. Five months earlier, the patient, who was late in planning a six-week trip to South America, had received vaccines against hepatitis B and yellow fever and had begun taking doxycycline…
Case Records of the Massachusetts General Hospital
Case 23-2003 — A 79-Year-Old Woman with Gastric Lymphoma and Erosive Mucosal and Cutaneous Lesions
Presentation of Case. A 79-year-old woman with a gastric B-cell lymphoma of the mucosa-associated lymphoid tissue (MALT) type was admitted to the hospital because of erosive mucosal and cutaneous lesions. The patient had been well until 14 months before admission, when she began to have cramping…
Case Records of the Massachusetts General Hospital
Case 24-2003 — A 10-Year-Old Girl with Recurrent Bouts of Abdominal Pain
Presentation of Case. A 10-year-old girl was admitted to the hospital because of abdominal pain, vomiting, and fever. She had been in excellent health until about 18 months earlier, when she had the first of several bouts of severe pain in the right lower quadrant; each episode of pain persisted…
Clinical Problem-Solving
A Wrinkle in Time
Foreword. In this Journal feature, information about a real patient is presented in stages (boldface type) to expert clinicians from several specialties, who respond to the information, sharing their reasoning with the reader (regular type). The authors' commentary follows. Stage. An 86-year-old…
An 86-year-old man presented with abdominal discomfort and fever. His medical history was notable for long-standing hypertension, mild chronic renal insufficiency, coronary-artery bypass surgery, repair of an abdominal aortic aneurysm seven years earlier, gout, diverticulitis, and prostatitis.
Case Records of the Massachusetts General Hospital
Case 25-2003 — A Newborn Boy with Petechiae and Thrombocytopenia
Presentation of Case. A newborn boy was admitted to a special-care nursery because of petechiae and thrombocytopenia. The boy had been delivered at this hospital at 39 weeks' gestation to a 32-year-old woman who had had premature rupture of the membranes 16 hours before delivery. A single dose of…
Case Records of the Massachusetts General Hospital
Case 26-2003 — A 50-Year-Old Colombian Man with Fever and Seizures
Presentation of Case. A 50-year-old man was admitted to the hospital because of fever, a seizure, and confusion. The patient was a native of Colombia who had traveled to the United States six weeks before admission to visit relatives. Two weeks before admission, he had had a respiratory infection…
Case Records of the Massachusetts General Hospital
Case 27-2003 — A 36-Year-Old Man with Recurrent Epigastric Pain and Elevated Amylase Levels
Presentation of Case. A 36-year-old man was referred to the hospital because of recurrent epigastric pain and persistently elevated amylase levels. The patient had been well until five months earlier, when he began to have epigastric pain. At that time, the amylase level was 349 U per liter (normal,…
Clinical Problem-Solving
Anatomy of a Diagnosis
Foreword. In this Journal feature, information about a real patient is presented in stages (boldface type) to expert clinicians from several specialties, who respond to the information, sharing their reasoning with the reader (regular type). The authors' commentary follows. Stage. A 33-year-old man…
A 33-year-old man presented for evaluation of hemoptysis. He had been in his usual state of health until the day of presentation, when he had a transient cough productive of one tablespoon (approximately 15 ml) of bright red blood. He did not have associated chest pain or dyspnea. He reported that he had not had recent weight loss, fever, illness, or trauma and that he did not have a history of bleeding.
Case Records of the Massachusetts General Hospital
Case 28-2003 — A 51-Year-Old Premenopausal Woman with Newly Diagnosed Breast Cancer and a Strong Family History of Breast Cancer
Presentation of Case. A 51-year-old, premenopausal woman came to this hospital with a newly diagnosed breast carcinoma and a strong family history of breast cancer. Three months earlier, on physical examination at another institution, a mass in the upper outer quadrant of the right breast had been…
Case Records of the Massachusetts General Hospital
Case 29-2003 — A 60-Year-Old Man with Fever, Rigors, and Sweats
Presentation of Case. A 60-year-old man was evaluated in the clinic in mid-June because of fever, rigors, and sweats. The patient had been well until 10 days earlier, when anorexia, a sore throat, diffuse myalgia, arthralgia, headache, malaise, and fever (temperature, up to 39.3°C) developed, with…
Case Records of the Massachusetts General Hospital
Case 30-2003 — A 21-Year-Old Man with Sudden Alteration of Mental Status
Presentation of Case. Dr. Joshua N. Goldstein (Emergency Medicine): A 21-year-old man was brought to the emergency department because of a sudden change in mental status. On the evening of admission, the patient had been consuming alcohol with friends. They noted that he had begun to act strangely,…
Case Records of the Massachusetts General Hospital
Case 31-2003 — A 44-Year-Old Man with HIV Infection and a Right Atrial Mass
Presentation of Case. A 44-year-old man was seen in the clinic because of a right atrial mass. Six years earlier, the patient had been found to have Pneumocystis carinii pneumonia and human immunodeficiency virus (HIV) infection. He had returned to a satisfactory state of health with the use of…
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Clinical Problem-Solving
Mind the Gap
Foreword. In this Journal feature, information about a real patient is presented in stages (boldface type) to expert clinicians from several specialties, who respond to the information, sharing their reasoning with the reader (regular type). The authors' commentary follows. Stage. A 62-year-old…
A 62-year-old woman with a history of acute myelogenous leukemia, who had undergone transplantation of T-cell–depleted allogeneic bone marrow two years earlier, was admitted to the hospital because of an elevated bilirubin level that was thought to be secondary to graft-versus-host disease. Her serum sodium level was 124 mmol per liter.
Case Records of the Massachusetts General Hospital
Case 32-2003 — A 37-Year-Old Woman with Atypical Squamous Cells on a Papanicolaou Smear
Presentation of Case. A 37-year-old woman was referred to the colposcopy clinic because of two Papanicolaou smears showing atypical squamous cells of undetermined significance (ASC-US). One and two years previously, the patient had had Papanicolaou smears that were reported to be normal. Six months…
Case Records of the Massachusetts General Hospital
Case 33-2003 — A 37-Year-Old Man with a History of Alcohol and Drug Abuse and Sudden Onset of Leg Weakness
Presentation of Case. A 37-year-old man was admitted to the hospital because of collapse. The patient was unmarried and unemployed and was a former smoker. He had abused alcohol since the age of 13 years and had been admitted for detoxification on numerous occasions because of alcohol abuse and use…
