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A 43-year-old woman with a history of metastatic breast cancer presented to the ED with three days of nausea, weakness, and abdominal discomfort.

Adenocarcinoma of the breast had been diagnosed two years earlier. At the time, she was treated with a mastectomy and adjuvant chemotherapy. Two months ago, the patient was found to have multiple nodular pulmonary metastases. She declined additional chemotherapy.

Over the past month, she noted an occasional nonproductive cough and dyspnea on exertion. Over the past three days, she had intermittent nausea, vomiting, and epigastric discomfort associated with poor oral intake. There was no fever, chills, chest pain, diarrhea, or constipation.

On examination, she was a well-developed and well-nourished female who appeared weak, but in no acute distress.

Her vital signs were—blood pressure 80/50 mm Hg, pulse 120 beats/min (irregular on palpation), respirations 24 breaths/min, temperature 99.2°F (rectal), SO2 96% on room air; when standing, the patient felt lightheaded and her blood pressure was 75/50 mm Hg and pulse 130 beats/min

There were scattered râles on lung examination. The heart was normal, abdomen non-tender and stool was negative for occult blood. There was no edema of the lower extremities.

Two liters of normal saline were administered by intravenous infusion over two hours. Afterwards, the patient stated that she felt better and was able to tolerate oral liquids. Repeat vital signs showed her blood pressure to be 110/70 mm Hg, pulse 90 beats/min (irregular), respirations 20 breaths/min. There were no orthostatic changes.

Blood tests including complete blood count, electrolytes, renal and liver functions were normal.

Her chest radiograph and EKG are shown (Figures 1 and 2).

After intravenous rehydration, she felt well enough to go home.

  • What would you do?

This patient, with a known malignancy, presented with nonspecific abdominal symptoms. These were accompanied by hypotension and tachycardia which were felt to have been caused by dehydration from poor oral intake. The patient improved with intravenous rehydration.

The chest radiograph shows multiple nodular opacities scattered throughout both lungs (Figure 1). These metastases were noted on a chest CT performed one month earlier (Figure 3). However, finding one radiographic abnormality should not distract you from noticing others. A systematic approach to radiograph interpretation can help to prevent such an error (see Introduction to Chest Radiology). Her heart is significantly enlarged (see Figure 4). Cardiac enlargement can be due to either a dilated cardiomyopathy or a pericardial effusion. Although an effusion is often described as producing a globular-shaped heart, it is usually not possible to differentiate ...

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