A 69-year-old woman is admitted to the hospital with respiratory distress and hypoxia due to pneumonia. She carriers a diagnosis of adenocarcinoma of unknown primary origin. Breast, GI, and gynecologic workups for the source of the adenocarcinoma are pending at the time of hospital admission. A tumor board has met and will decide on therapeutic options. Her medical history also includes hypertension, rheumatoid arthritis, and a chronic pleural effusion (secondary to the rheumatoid arthritis).
A 69-year-old man with a history of bipolar disorder, hypothyroidism, and tobacco abuse is admitted to the hospital with mental status changes, leukocytosis (WBC count, 31,000 cells/μL), and a right upper lobe lung mass. Empiric therapy for infection was not effective. CT scans demonstrate the lung mass and lesions to liver and bone to be consistent with metastases. The patient was unable to undergo bronchoscopy due to diminished mental status. The testing of other biopsy specimens was nondiagnostic. He is capable of minimal self-care and has osteoarthritis in addition to those medical problems mentioned earlier.
A 66-year-old man with known metastatic prostate cancer (stage D3) that was diagnosed 6 years prior to admission, is admitted to the hospital for C and T spinal cord compression. He is not a surgical candidate despite severe back pain, urinary incontinence, and lower extremity weakness and numbness. Despite radiation therapy, he requires a morphine elixir and fentanyl patches for pain. He is unable to transfer from his bed to a chair without pain. The cancer is resistant to hormonal treatments offered by urology specialists. His medical history also includes diabetes, asthma, bilateral orchiectomy 6 years ago, and a 30-year smoking history.
A 71-year-old man is admitted for nausea, vomiting, fever, and hip pain. He had experienced stage D2 prostate cancer that had been treated with a radical prostatectomy 6 years prior to hospital admission. He had had an elevated prostate-specific antigen level 4 years ago, and 2 years ago had experienced fevers, anorexia, and hip, leg, and back pain. A bone scan demonstrated diffuse bony metastases. He was treated with hormonal therapy and experienced an improvement in his symptoms. Since that time, he has experienced fevers (temperature, up to 102.5°F), diaphoresis (three to five times daily), severe back pain, hip pain, and chronic analgesic use (ie, up to 20 tablets of acetaminophen with codeine daily). He also reports a recent 8-lb weight loss. His medical history is remarkable for pulmonary emboli 6 and 7 years prior to hospital admission, basal cell carcinoma, and diverticulosis.
A 78-year-old man with a 10-year history of multi-infarct dementia is admitted to the hospital after an episode of GI bleeding and was awaiting nursing home placement. His medical problems are gout, gastric ulcers, hypertension, and chronic renal insufficiency.
A 31-year-old HIV-positive man who had experienced Pneumocystis pneumonia on four occasions in the past is admitted to the hospital for headache, nausea, and vomiting. A previous hospital admission demonstrated an EEG trace that was perhaps consistent with herpes encephalitis. The patient was admitted to the hospital for empiric IV acyclovir therapy until cerebrospinal fluid studies return. His CD4 count was < 50 cells/μL. Other history includes Mycobacterium avium intracellulare infection, abnormal results of liver function tests, asthma, and hypothyroidism.
A 64-year-old man is admitted to the hospital for the evaluation of possible spinal cord compression. Prostate cancer that had been diagnosed 2 years prior to hospital admission was treated with prostatectomy and radiotherapy. He had an orchiectomy 1 year ago. The patient developed back pain, and a subsequent bone scan showed bony metastases. He received maximum dose of radiation therapy with some resulting relief of pain, but a follow-up bone scan showed disease progression. Pain is controlled by sustained-release morphine therapy. The patient is admitted with a 1-week history of burning sensations from ankles to waist, without incontinence or gait disturbance. The patient has lost 20 lb. His medical history is significant for type II diabetes and a history of heavy smoking.
A 35-year-old man who is HIV-positive, has a history of Pneumocystis carinii pneumonia, and a CD4 cell count of < 5 cells/μL was admitted for cough and shortness of breath. Bronchoscopy reveals P carinii pneumonia. The patient has had two recent hospital admissions for Pseudomonas pneumonia and Staphylococcus aureus empyema. He is currently receiving prophylaxis therapy with dapsone. His medical history includes Stevens-Johnson syndrome secondary to trimethoprim/sulfamethoxazole, reactive-airways disease, and hypertension.
A 64-year-old man with dialysis-dependent renal failure, hypertension, CHF, and insulin-dependent diabetes complicated by nephropathy, polyneuropathy, and retinopathy (ie, the patient is blind) is admitted to the hospital after 4 days of diarrhea, abdominal pain, decreased oral intake and lightheadedness. The patient fell 2 weeks ago and still has right shoulder pain. He has diabetic neuropathy ambulates with assistance.
A 54-year-old man with alcoholic cirrhosis and continued alcohol dependence is admitted to the hospital with GI bleeding. He was admitted to the hospital twice several months ago with esophageal variceal bleeding and was treated with sclerotherapy. On this hospital admission, he is admitted to the medical ICU where an endoscopy reveals a gastric ulcer. He was noted to have mental status changes on hospital admission, which persisted until his transfer to the general medicine wards. He is not currently a liver transplant candidate due to his continued alcohol abuse. His medical history includes hepatic encephalopathy, hepatitis B and C infections, thrombocytopenia, coagulopathy, and mitral regurgitation.
A 55-year-old woman with metastatic breast cancer is admitted to the hospital for a transfusion that is required for symptomatic anemia due to chemotherapy. The breast cancer was diagnosed 2 years ago, and the patient underwent a modified radical mastectomy of the left breast. The following year, she was found to have spinal cord metastases and was treated with surgery and radiotherapy. Several months ago, she was found to have lymph node and right hip metastases. Chemotherapy was initiated and was changed shortly before hospital admission. She has received two cycles of the new therapy. She was admitted to the hospital for shortness of breath and a hematocrit of 23.5 (WBC count, 0.4 cells/μL). The patient was found to be febrile on hospital admission. In addition to breast cancer, the patient’s medical history includes a recent exacerbation of herpes-zoster virus.
A 72-year-old man is admitted to the hospital through the emergency department for fevers. The patient has chronic lymphocytic leukemia, which was first diagnosed 4 years ago as an incidental finding on routine blood work. He has undergone two cycles of chemotherapy with cyclophosphamide, doxorubicin, vincristine, and prednisone (last received shortly before hospital admission) with minimal response. During the past year, he has been hospitalized four times for fever, with and without neutropenia, without the etiology having been identified. He was scheduled for hospital admission for an RBC transfusion but reported 2 days early for a fever of 102°F and worsening fatigue. On hospital admission, his absolute neutrophil count was 920 cells/μL, his hemoglobin count was 6.6 cells/μL, and his platelet count was 46,000 cells/μL. In addition to his chronic lymphocytic leukemia, his medical history includes stage C prostate cancer (treated with a radical prostatectomy 4 years ago), diverticulosis, colon polyps, Raynaud’s syndrome, and congenital lung cysts.
A 68-year-old man is admitted to the rehabilitation service for therapy and education following a below-the-knee amputation of the right leg for diabetic ulcers. He recently spent 3 months in a nursing home rehabilitating but is still unable to perform his activities of daily living. He was noted to have abdominal distention and a partial bowel obstruction. Education was incomplete during his stay due to deafness and waning mental status. He is noted to be incontinent of urine and stool by the nursing staff. His medical history includes insulin-requiring diabetes, alcoholic cirrhosis, COPD, chronic renal insufficiency, atrial fibrillation, dilated cardiomyopathy, CHF, and peripheral vascular disease.
A 46-year-old woman with metastatic breast cancer is admitted to the hospital with fevers and chills due to infection around an indwelling catheter. Her breast cancer was diagnosed 5 years ago, and she has undergone a modified radical mastectomy, cyclophosphamide/doxorbicin/5-fluorouracil chemotherapy (six cycles), and radiation therapy to her tumor-positive axillary nodes. She was found to have metastases to her right humerus 2 years ago and experienced a pathologic left femur fracture shortly thereafter, which was treated with surgery and radiotherapy. Paclitaxel (Taxol; Bristol-Myers Squibb; Princeton, NJ) therapy was initiated 1 year ago, which ended shortly before this hospital admission. The patient’s medical history includes hypertension.
A 79-year-old man with recently diagnosed unresectable squamous cell carcinoma of the esophagus, which had been treated with two cycles of chemotherapy, is admitted to the hospital with pneumonia in the right middle lobe and right lower lobe. The patient also received local radiation therapy. His most recent chemotherapy was 1 week ago. His medical history also includes COPD, chronic atrial fibrillation, coronary artery disease (four-vessel), abdominal aortic aneurysm, hypertension, and embolic strokes without residual deficits.
A 67-year-old man with squamous cell cancer of the tonsils (stage T2N2M0) who underwent a left radical neck dissection and mandibulectomy 1 year ago and who now has a lytic lesion on the L5 vertebral body was admitted to the hospital. The patient is transferred for evaluation and possible radiation therapy of this lesion. An evaluation later demonstrates liver masses. Biopsy specimens of both the liver lesion and vertebral body lesion show metastatic disease. His medical history includes benign prostatic hypertrophy.
An 83-year-old woman with hepatitis C cirrhosis presents with progressive ascites and pancytopenia that is thought to be secondary to splenic sequestration from portal hypertension. Her medical history is remarkable for hypertension and degenerative joint disease.
A 28-year-old man with AIDS and a CD4 count of 5 cells/μL is admitted to the hospital for bilateral eye pressure, sinus congestion with copious yellow mucous discharge, low-grade fever, and cough associated with emesis. His course has been complicated by early AIDS dementia, HIV-associated immune thrombocytopenic purpura, and thrush.
A 27-year-old HIV-positive man with a CD4 cell count of 39 cells/μL is admitted to the hospital after 4 days of confusion and bizarre behavior. He has some agitation and hallucinations. His family has noted diminished cognitive function over the previous several months. He denies alcohol or drug use. He has a history of oral thrush, P carinii pneumonia (2 years ago), and disseminated Kaposi’s sarcoma, which had been treated in the past with multiple cycles of vincristine and bleomycin followed by radiation therapy. The bleomycin therapy was complicated by a decreased pulmonary diffusion capacity.
A 66-year-old man with multiple medical problems including atherosclerotic coronary artery disease, end-stage renal disease receiving dialysis three times weekly, and diabetes presented to the emergency department with complaints of weakness, “feeling funny,” and shortness of breath. He was found to be hyperkalemic with a large right pleural effusion. Arterial blood gas measurements taken on admission to the hospital were remarkable for the following: pH, 7.36; Pco2, 44 mm Hg; and Po2, 45 mm Hg. He had had a hospital admission 1 year ago for a similar effusion. A thoracentesis at that time revealed abnormal cytology, suggesting an adenocarcinoma, but the patient was lost to follow-up. His medical history is remarkable for a four-vessel heart bypass surgery, severe CHF (ejection fraction, approximately 20%), anemia, thrombocytopenia, aortic valve replacement, atrial fibrillation, and cirrhosis.