J. Paul Miller, MD


Sudden Loss of Consciousness in an Elderly Woman

October 01, 2007

A comatose 82-year-old woman is brought to the emergency department. Her husband reports that after dinner she began to have difficulty in speaking, lost consciousness, and fell to the floor. He tried to rouse her, but was unsuccessful and called for an ambulance.

Man With Weakness, Dyspnea, and Ataxia

January 01, 2007

For 3 months, a 66-year-old retired man has had increasingweakness of the lower legs with stiffness,tingling, and numbness; worsening ataxia; anergia; andexertional dyspnea of insidious onset. He has lost 8 lb,and his appetite is poor. He denies fever, cough, chest orabdominal pain, paroxysmal nocturnal dyspnea, orthopnea,ankle swelling, bleeding disorders, hematemesis,melena, headache, vision problems, sciatica, joint pain,bladder or bowel dysfunction, and GI symptoms. He hasnocturia attributable to benign prostatic hypertrophy.

Octogenarian With Intermittent Confusion

December 31, 2006

Intermittent, worsening confusion recently developed inan 82-year-old man. His daughter brings him to the officefor evaluation.

Elderly Man With Fatigue and Backache

December 31, 2006

A70-year-old African American man, who is a retiredelectrician, presents with increasing fatigue anddull back pain of 4 months’ duration. Although he usuallywalks about 2 miles a day, he now becomes exhaustedafter half a block. He reports exertional dyspnea but noparoxysmal nocturnal dyspnea or orthopnea. Recently, henoticed ankle edema.

Young Woman With Sore Throat and Extreme Fatigue

December 31, 2006

An 18-year-old college studentpresents with a 4-day history ofincreasing throat pain, low-gradefever, and extreme exhaustion. Previously,she had been healthy and participatedactively in sports, includingmarathon running. Her appetiteand intake have been poor. No historyof cough, chest pain, shortness ofbreath, nausea, vomiting, diarrhea,or abdominal distention. She has noallergies, takes no medications, anddoes not smoke or drink alcohol.She is sexually active with a single partner.

What's Wrong With This Picture?

April 15, 2006

A 24-year-old woman presents tothe emergency department withincreasing left lower quadrant pain,nausea, and persistent retching andvomiting of 48 hours’ duration. Thepain ranges from dull and aching tocramping; it has become generalized,and there is no specific relieving factor.During the last 12 hours, she hasalso had fever and chills. She has nourinary symptoms, hematemesis,melena, diarrhea, constipation, or abdominaldistention.

Man With Severe Flank Pain and Nausea

November 01, 2005

A previously healthy 40-year-old man presents with a 2-hour history of excruciating colicky pain of acute onset that emanates from the right flank and radiates to the groin. He rates the severity of the pain at 9 on a scale of 1 to 10. Before arriving at the emergency department, the patient experienced nausea and 2 episodes of nonbilious, nonbloody vomiting.