Mukund

Congrats, Vale.

That's incredibly good news.

I am about eight months ahead of you.

I'm just finishing my first year of residency.

I think while it's been difficult, it's also been one of the best years of my life.

The learning curve is absolutely incredible, and every day is just filled with learning.

Yeah, I'm having a blast.

That sounds great.

This was a really tough case and probably one of the more difficult clinical problem solving exercises I've run into an intern year so far.

So good luck, you guys.

But this is an 84 year old guy who was presenting to the hospital with sudden right upper quadrant pain, kind of sharp, stabbing, woke him up from his sleep and he classified it as a nine out of 10.

It lasted for a few minutes at a time, and it came back a few times, and that's what prompted him to call an ambulance to come to the hospital.

On further questioning, denied any fevers, chills, dark urine, bloody stool, pale stool, chest or back pain.

But if you dig into the history a little further, you find out that he also has a couple other kind of more subacute or chronic concerns.

First, a three-week history of progressive abdominal distension and worsening shortness of breath.

He does say that he was in his usual state of health until he was hospitalized a few months ago for fall.

And in that hospitalization, he was found to have a large gluteal hematoma.

He stayed in the hospital for a long time and he was discharged to rehab, severely deconditioned.

Since his rehab stage is a few months ago, he's lost 45 pounds and says he has had very poor appetite.

His past medical history is notable for heart failure with preserved ejection fraction with the last EF in the 50 to 55% range.