No abstract

No abstract

The patient is a 68-year-old female with hypertension, chronic obstructive pulmonary disease, without medical follow-up for several years, who initially presented with skin blisters and oral lesions, which were biopsied by her dermatologist and found to be bullous pemphigoid. She was treated with a course of oral prednisone and had resolution of her skin and oral lesions. Three months later, she presented with a swollen leg and was diagnosed with a deep venous thrombosis, for which she was started on coumadin and had an inferior vena cava filter placed. She then had hemoptysis a few days later, after which the coumadin was held. A chest computed tomography (CT) done at that time found a right middle lobe consolidation consistent with aspiration pneumonia and a cavitary lesion in the left upper lobe of her lung, which was biopsied and found to be a necrotizing cavitary lung lesion. After being ruled out for tuberculosis, she had an outpatient positron emission tomography (PET) scan which was positive for a 2.7cm left lower lobe cavitary lesion and a 9 cm pelvic mass with hypermetabolic activity, as well as small liver lesions. Concurrently, she complained of dysphagia and 30-lbs of weight loss over the prior six months, so the decision was made to undergo an outpatient esophagogastroduodenoscopy (EGD). The EGD could not be completed secondary to a stricture in the distal esophagus; however, pemphigus ulcers were seen in the mouth and esophagus. Given the patient's degree of malnourishment and dehydration, she was admitted to the outside hospital. On admission, she was found to have leukocytosis with a white blood cell count of 37,000/L, hypercalcemia with a calcium of 13mg/dL, hypotension, and acute renal failure with a creatinine of 4.4mg/dL. Her parathyroid hormone-related protein (PTHrP) was 105 pmol/L (normal <1.3 pmol/L), while her intact parathyroid hormone (PTH) was <3pg/mL (10-55 pg/ml). A serum protein electrophoresis with immunoelectrophoreis was positive for an IgG lambda paraprotein. On bone marrow biopsy, there were 25% plasma cells consistent with multiple myeloma, though this diagnosis was questioned after transfer. For treatment of her hypercalcemia, she was given intravenous fluids and calcitonin with minimal improvement, but with resolution of her renal failure.The esophageal biopsy showed squamous mucosa with necrotic ulcer and chronic inflammation with fibrinous exudate. The pelvic mass was also biopsied which was consistent with carcinosarcoma with massive necrosis. The pathology revealed myxoid high-grade spindle cell sarcoma with pleomorphosis and extensive mitosis and poorly differentiated adenocarcinoma with papillary serous differentiation, as well as some smooth muscle differentiation. During her hospitalization, the skin blisters reappeared and were biopsied. The biopsy was consistent with paraneoplastic pemphigus. She was treated with three days of intravenous immunoglobulin (IVIg). She had an open jejunostomy tube placed for nutrition. At this point, she was transferred to Thomas Jef...

A 38-year-old female with a medical history significant only for a cholecystectomy for cholelithiasis presented to an outside hospital with a one day history of sharp, non-radiating midsternal chest pain that began when she bent over to pick something up. She has associated light-headedness and dizziness when she stood up, as well as palpitations, diaphoresis, and a sense of throbbing in her left arm. The symptoms persisted at rest for one hour before the patient arrived at the outside hospital. She was found to be in new-onset atrial fibrillation with a rapid ventricular rate up to 160 beats per minute. A diltiazem infusion was started which resulted in a decrease of the heart rate to 100 beats per minute. Her first troponin was <0.05 ng/ mL, but a subsequent troponin was 0.59 ng/mL, prompting the initiation of a heparin infusion for acute coronary syndrome. At this point, she was transferred to Thomas Jefferson University Hospital for further management. Her chest pain had resolved without any other medication, and she remained chest pain free through the rest of her hospital course. Of note, she admitted to using alcohol, tobacco, and cocaine two days prior to admission. Her only medication is a daily oral contraceptive pill.Her initial vital signs on transfer were a temperature of 97.9 degrees Fahrenheit, blood pressure of 97/63 mm Hg, heart rate on 112 beats per min, which was irregularly irregular, and respiratory rate of 20 breaths per minute with an oxygen saturation of 98% on room air. Her physical exam was significant for an enlarged left palatine tonsil, irregular heart rate, and ecchymosis on her neck.Initial laboratory studies included a white blood cell count of 12,000 /L, hemoglobin of 14.1 g/dL, platelet count of 269,000 /L, creatinine of 1.1 mg/dL, AST 48 IU/L, and ALT 41 IU/L. Her maximum troponin was 0.59 ng/mL. Subsequently, her rhythm converted to sinus rhythm. Her EKG showed sinus tachycardia, but no ST-T changes concerning for myocardial ischemia or infarction.A cardiac catheterization was done with images as shown below.Questions: Select the one lettered answer that is BEST in each question.