Intern Report 8.16


Case Discussion presented by Wissam Rhayem, MD


Chief Complaint:  “Chest Pain”

History of Present Illness:

This is a 26 y/o male prisoner presenting with a chief complaint of chest pain and palpitations.

The patient has a history of Wolff-Parkinson-White and poly-substance abuse. He states that he takes 20-40 mg of Xanax daily along with any Ativan, Klonopin, and Seroquel that he can obtain. The story is unclear, but the patient claims that he has been taking Xanax while in prison. The patient has been in prison for the last 9 days. He denies nausea, vomiting, headache, diarrhea, constipation, visual changes, fever, chills, or difficulty breathing.

Medications: Xanax 20-40 mg daily; Ativan; Klonopin; Seroquel; none are prescription

PMH: Wolff-Parkinson-White

Social History: + cannabis; + cigarettes; + alcohol weekly


Physical Exam:

VITALS: BP 127/80 HR 104 bpm T 36.1°C RR 16 bpm SpO2 98%

General: severe distress; agitated; not oriented

HEENT: pupils 3 mm; PERRL; EOMI; atraumatic

CV: regular rate and rhythm; no murmurs, rubs, or gallops

Pulmonary: breath sounds are clear bilaterally without rales, rhonchi or wheezing.

GI: soft, nontender, nondistended; no palpable masses

Musculoskeletal: no deformity; full ROM in all four extremities

Skin: no cyanosis; good perfusion in all four extremities; palpable pulses in all extremities

Neuro: not oriented; uncooperative; no focal deficits; normal deep tendon reflexes

Psych: uncooperative; agitated; labile mood; hostile; belligerent; pressured speech


EKG: no delta wave; shortened PR interval; normal sinus rhythm

BMP: Na 139; K 4.0; Cl 104; CO2 30; BUN 11; Creatinine 0.99; Glucose 117

CBC: WBC 9.1; HgB 14.7; Hct 44.2; Plt 220

UDS: + BZDA; + cannabinoids

TROP: < 0.017 x 2


Medical Course:

While the patient is waiting for transfer to CDU,  his mental status begins to deteriorate. Now at 24 hours after initial presentation, he starts having visual hallucinations and becoming very agitated and delirious. He is demanding “footballs” and “candy bars.” The patient is screaming and is very verbally abusive. He is tugging violently at his restraints and is fighting to get out of bed. He does not respond to an initial 10 mg of IV Valium (diazepam). He is then given 10 mg, then 20 mg, then 40 mg, then 80 mg of IV Valium, each 5 minutes apart, until light sedation is achieved. At this point, he reports that his chest pain has resolved.

After about 90 minutes of sleep the patient sits straight up in bed, screaming for a urinal. The patient is now tachycardic and hypertensive. He is given a urinal and voids 900 mL of urine. Tachycardia and hypertension immediately resolve. He is noted to have tongue fasciculations and hand tremors at this time. He starts to become extremely agitated again and is given 20 mg, then 40 mg, then 80 mg, and then 160 mg of IV Valium each 5 minutes apart until he sleeps. A foley is placed to avoid further urinary retention.

Hospital pharmacy warns that they are running out of Valium. A propofol drip is then started. In the process of starting the drip, the patient becomes agitated again and requires 40 mg of IV Valium, followed by another 40 mg of IV Valium 5 minutes later. The drip is started at 20 mcg/kg/min. The patient is lightly sedated at this point, but continues trying to get out of bed. The drip is increased to 30 mcg/kg/min and the patient achieves light sleep. He is asleep soundly and snoring but responds to verbal stimuli. Saturations remain at 98% without supplementary oxygen. He is admitted to the MICU.



1. Which of these is indicated in treatment of acute benzodiazepine overdose?

A. activated charcoal

B. gastric lavage

C. flumazenil

D. naloxone

E. supportive care


2. What are sequelae of benzodiazepine withdrawals?

A. agitation

B. seizures

C. hallucinations

D. nausea

E. all of the above


3. Which BZDA has a risk of propylene glycol poisoning when given IV for prolonged periods?

A. ativan/lorazepam

B. versed/midazolam

C. xanax/alprazolam

D. klonopin/clonazepam

E. onfi/clobazam



4. What is the approximate LD50 of Valium (diazepam)?

A. 1 mg/kg

B. 10 mg/kg

C. 100 mg/kg

D. 1000 mg/kg

E. unknown

Filed under: Intern Report, Toxicology

Senior Report 8.15


Case Presentation by Brian Holowecky, MD

CHIEF COMPLAINT  “I have a sore throat and I cannot breathe”

54-year-old female presents to the emergency department brought by ambulance for sore throat. She states she has had a sore throat since this morning and it has been getting progressively worse. Her throat feels like it is “closing up.” She called the ambulance because she was having increasing difficulty catching her breath. She feels a swelling in her throat which is causing her to be unable to drink or eat anything. She has a history of allergy to lisinopril. She has had angioedema reactions.  She admits to using crack cocaine last night out of a pipe in which she has done many times in the past. No fevers. No upper respiratory symptoms recently. No recent coryza symptoms. On further questioning she states that but used a larger amount of cocaine than usual last night.

REVIEW OF SYSTEMS:  Negative except as in HPI

PAST MEDICAL/SURGICAL HISTORY  History of angioedema, Hypertension, diabetes, asthma, bipolar disorder,
MEDICATIONS:  Albuterol, fluticasone, fluoxetine, clonidine, amlodipine, loratadine, omeprazole.
ALLERGIES:  Lisinopril, anaphylactic.
SOCIAL HISTORY:  Tobacco use, recent crack cocaine use yesterday by a pipe inhalation, heroin abuse. Recently attempted inpatient rehabilitation for drug abuse.

Vitals: BP 166/93 heart rate 58 respirations 16 temp 37.0 saturation 100% on room air.
General: Well nourished patient appearing mildly toxic in respiratory distress. She is hoarse. There is some questionable stridor.

HEENT:  Posterior pharynx is mildly erythematous initially. Mucuous membranes moist. No cobblestoning. Uvula is midline. Mallampati score is 2. Lips are not swollen. No periorbital edema.

Cardiovascular:  S1 S2. RRR. No murmurs. Peripheral pulses equal bilaterally.

Respiratory: Hoarse voice. Stridor. Increased work of breathing. Sitting forward in sniffing position. Breath sounds are equal. No wheeze or crackles. Tolerating secretions initially.

Gastrointestinal:  Soft, NT ND. No rebound, guarding, or rigidity.

MSK/Extremities:  No gross deformities. No joint swelling, erythema. No edema.

Skin:  Warm and dry. No rashes, bruises, or abrasions.

Neurologic:  Alert and Oriented. Follows commands. No facial asymmetry noted. Motor and sensation intact.

Medical Course:  
Initially concerned for anaphylactic reaction in this patient with a known history of anaphylaxis. She was appearing very anxious and beginning not to tolerate her secretions very well. There was slight drooling. I was concerned based on her deterioration for anaphylactic reaction. She began to get more hoarse of voice and to sit forward in the sniffing position. There was questionable stridor.

She received 0.1 mg of epinephrine IM, along with Zantac, 125 mg of Solu-Medrol, 50 mg of IV Benadryl. She did improve somewhat at that time.

The working diagnosis was possible anaphylactic reaction versus anxiety or panic attack. This is a patient with a known psychiatric disorder. She was placed on the cardiac monitors and continuous pulse ox. IV access was established. She began to tolerate her secretions better at that time. Her heart rate remained in the 50s to 60s. Saturation remained 100% on room air.

About 90 minutes into her ER visit, she appears to be worsening and begins tripoding, drooling more profoundly and acting considerably more anxious.  Shas never had any visible airway swelling.

A lateral neck xray is taken:



1) What is the most likely cause for her condition?
A) Anaphylactic reaction from unknown source
B) Thermal pharyngeal Injury
C)Neoplastic transformation of a previously benign lesion
D)That is a normal lateral neck xray. There is no abnormality.

2) What is the treatment for her condition?
A) Urgent intubation in a controlled environment
B) Admission an ICU for close airway monitoring
C) Steroids, antihistamines, and H2 blockers.
D) Antibiotics and ENT consult for drainage.

3) If you suspect anaphylaxis, what is the appropriate initial treatment?
A) 0.3 mg epi subQ, 50mg diphenhydramine, 150 mg ranitidine, steroid
B) 0.3 mg epi IM, 50mg diphenhydramine, 150 mg ranitidine, steroid
C) 0.1 mg epi sub Q, 50mg diphenhydramine, 150 mg ranitidine, steroid
D) 0.1 mg epi IM, 50mg diphenhydramine, 150 mg ranitidine, steroid

Bonus Question 1: Should an epipen be administed into the thigh of the person with the suspected anaphylactic reaction, or into the thumb of the person holding the autoinjector?
A) Thigh
B) Thumb

Bonus Question 2:  Do vaccines cause autism?
A) Yes
B) No

Filed under: Senior Report

Intern Report 8.14


Case Presented by Brett Sorge, MD

CHIEF COMPLAINT(S): Chest pain and SOB

This is a 67 yo male with HTN, hyperlipidemia and DM who presents with chest pain. His chest pain started this morning (14 hours ago) and is pressure-like and located around the center of his chest. The pain does not radiate, and has not gone away. He is having SOB as well, and feels like he has worse pain with deep breaths. He has had chills since this morning. He has had nausea and vomiting starting today as well. He has had four episodes of non-bloody vomiting total. He admits to a separate epigastric pain as well, that is worse with defecation. The pain does not radiate, and comes and goes. Previous to this morning, he had been tolerating diet with no N/V. He has had pale colored stool ever since a cholecystectomy 3 months ago and has noticed “Vernors”-colored urine. He denies skin changes, itching, or yellowing of his eyes. He denies recent travel, smoking, cough, diarrhea, bright red blood per vomit/rectum, history of cancer or blood clots.

CONSTITUTIONAL: No weight loss.
HEENT: No loss in vision, No runny nose.
SKIN: No rash
GASTROINTESTINAL: No black or bloody stools.
GENITOURINARY: No burning on urination.
MUSCULOSKELETAL: No loss of muscle function.
HEMATOLOGIC: No history of easy bruising.
LYMPHATICS: No history of splenectomy.
PSYCHIATRIC: No history of depression or anxiety.
ENDOCRINE: No polyuria or polydipsia.
ALLERGIES: No history of asthma.

PMD: Patient says he goes to an outside provider for his primary care

PAST MEDICAL HISTORY: Hyperlipidemia, hypertension, diabetes
SURGICAL HISTORY: Cholecystectomy 3 months ago, s/p laparotomy from GSW 30 yrs ago
MEDICATIONS: Patient does not know medications he takes – EMR- metoprolol 50 QD, amlodipine 5 mg QD, losartan 100 QD, atorvastatin 40 QHS, pioglitazone 45 QD
ALLERGIES: Lisinopril
SOCIAL HISTORY: Denies smoking cigarettes, drink alcohol, drug use
FAMILY HISTORY: No family history of early MIs

General: Laying in bed, appears uncomfortable.
Vitals: Blood pressure 215/94, pulse 90, respirations 16, temperature 38.1. Pulse oximetry 100% on room air
HEENT: Head exam was generally normal. No scleral icterus. Mucous membranes were moist.
Cardiovascular: Regular rate and rhythm, no murmurs rubs or gallops
Respiratory: Clear to auscultation bilaterally
Gastrointestinal: Tender to palpation of the epigastric area, soft, non-distended, + BS, multiple scars from previous surgeries
Musculoskeletal: Able to move all extremities
Neurologic: Neurologically, the patient was awake, alert, and oriented to person, place and time. There were no obvious focal neurologic abnormalities. No asterixis or tremor noted.

BMP – 138/3.7/103/25/14/0.86/158 Ca – 9.6
LFT – ALT-724, AST-1637, Alk Phos – 379, t bili – 2.2, d bili – 1.4
Lipase – 63, Ammonia – 69, Lactic Acid – 2.6
CBC – 15.4/13.5/41.7/251
Coags – 23.1, 11.3, 1.06
Troponin – <0.017
EKG – normal
CXR – normal
US RUQ- dilated common bile duct without signs of stone, abscess, or an intra-hepatic process



1. What is the most common symptom in ascending cholangitis?
A. Malaise
B. Jaundice
C. Fever
D. RUQ pain

2. What is the mortality without surgical decompression after 72 hours?
A. 30%
B. 60%
C. 85%
D. 100%

3. Of the answers provided, which antimicrobial therapy is best for empiric therapy for severe cholangitis?
A. azithromycin
B. ceftriaxone
C. ceftriaxone and metronidazole
D. vancomycin

Filed under: Intern Report

Intern Report 8.13


Case Presentation by Lauren Kroll, MD

Chief complaint: “I can’t breathe.”

This patient is a 49 year old female with a past medical history of alcohol abuse who presents to the Emergency Department as a medical code for difficulty in breathing. The patient states her difficulty in breathing started gradually last night, and that it is getting progressively worse. She has never experienced anything like this before. She denies fever, chills, cough, congestion, chest pain, and leg swelling. She does admit to some mild epigastric pain, which has been present for the past two days. The epigastric pain is accompanied by nausea and multiple episodes of non-bloody, non-bilious vomiting.

Past medical history: Hypothyroidism, seizure disorder, deep venous thrombosis (diagnosed in December 2014), alcoholism.
Past surgical history: None.
Medications: None (the patient does state she is supposed to be on both levothyroxine and coumadin).
Allergies: Dilantin, phenobarbital.
Social history: Significant for both tobacco and heavy alcohol abuse. No intravenous drug abuse.

Vitals: BP 119/84, HR 126, RR 38, T 35.4, SaO2 99% (room air)

General: Well developed African American female in respiratory distress.

HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. Dry mucous membranes. No pharyngeal erythema. The patient’s breath has a fruity odor.

Cardiovascular: Tachycardic, regular rhythm. No murmurs. No jugular venous distention, no edema.

Respiratory: Tachypnic. Lungs clear to auscultation bilaterally, no wheezes or crackles. No accessory muscle use, no retractions.

Gastrointestinal: Abdomen soft, slightly tender to palpation in the epigastric area, and non-distended. No rebound tenderness, no guarding. Bowel sounds present.

Neurologic: Alert and oriented x 3. Strength equal in all four extremities.

Skin: Warm, dry.

ecg kroll

Laboratory studies:

Basic metabolic panel: Na 137, K 4, Cl 98, HCO3 5, BUN 13, Cr 1.06, glucose 122

Complete blood count: WBC 15.7, Hb 14.2, Hct 43.5, platelets 338

Coagulation studies: PT 10.9, PTT 29.2, INR 1.03

Arterial blood gas: pH 6.879, pCO2 22.1, pO2 95, HCO3 4

Beta-hydroxybutyrate 77.5 (normal 0.2 – 2.8)

Troponin <0.017


Liver function tests: amylase 97, lipase 888, total bilirubin 0.4, direct bilirubin 0.1, ALT 21, AST 68, alkaline phosphatase 98, albumin 2.9

EtOH 151

Urinalysis: 2+ ketones, 2+ protein, specific gravity 1.010, otherwise unremarkable

Chest x-ray:
cxr kroll

The patient’s acid base status is best described as which of the following?
A) anion gap metabolic acidosis (with complete respiratory compensation)
B) non-anion gap metabolic acidosis (with complete respiratory compensation)
C) anion gap metabolic acidosis (with incomplete respiratory compensation)
D) non-anion gap metabolic acidosis (with incomplete respiratory compensation)

2. Initial Emergency Department fluid management for this patient should include which of the following?
A) 5% dextrose in normal saline + insulin
B) 5% dextrose in normal saline + thiamine
C) 5% dextrose in water + thiamine
D) 5% dextrose in water + 3 amps of NaHCO3

3. As the patient is treated in the Emergency Department, which of the following would be expected with repeat blood draws and urinalysis?
A) beta-hydroxybutyrate will decrease; urine ketones will decrease
B) beta-hydroxybutyrate will decrease; urine ketones will remain unchanged
C) beta-hydroxybutyrate will increase then decrease; urine ketones will decrease
D) beta-hydroxybutyrate will decrease; urine ketones will increase then decrease

Filed under: Intern Report

Intern Report 8.12


Case Presentation by Jacob Jensen, MD

Chief complaint: nausea and vomiting

HPI: Patient is a 28 year old female with past medical history of developmental delay, schizophrenia, and hypothyroidism transferred to the ED from a skilled nursing facility for nausea and vomiting. Patient is not responding to questions, she is not accompanied by family or nursing home staff, and EMS is unable to supply further details. Per EMR review, patient is often transferred to this or other nearby hospitals with similar complaints (especially the day before holiday weekends).

ROS: Could not be obtained 2/2 patient’s underlying medical presentation.

PMH: Developmental delay, schizophrenia, hypothyroidism

PSH: There is a reference to an X-lap in the EMR but no explanation as to when or why it was performed.

SHx: Patient has resided in a skilled nursing facility for at least the last 10 years


Meds: seroquel, trazadone, respiredone, cogentin, synthroid,

Physical exam:
Vitals: T 36.4 Oral, HR 137, BP 49/33, RR 22, SpO2 97% on room air
General: Alert but non-verbal
Eye: Extraocular movements are intact
HENT: Normocephalic, Atraumatic, Oral mucosa is dry
Respiratory: Respirations are non-labored
Cardiovascular: Normal S1, S2, no murmurs, rubs, or gallops
Gastrointestinal: Soft, mildly distended, no rebound or guarding
Musculoskeletal: No deformity
Integumentary: Cool, dry, intact

Course in the ED:
Patient was triaged to resuscitation bay due to hypotension with tachycardia. A 16 gauge IV was started and patient was given 2L normal saline. On repeat testing, patients HR had decreased to 118 and BP had increased to 92/70.

Patient had one witnessed episode of vomiting in the ED. The vomitus smelled feculent so an NGT was placed. 300mL of yellow-green gastric contents was returned.

Basic labs were as follows; Bedside Glucose unremarkable, Lactic Acid 9.7, BMP unremarkable, CBC remarkable for leukocytosis of 13.1 with absolute neutrophil count of 9.7, coags unremarkable, urinalysis unremarkable, and urine pregnancy negative.

Chest X-ray was unremarkable.

EKG was unremarkable.

Abdominal series was obtained and read as suggestive of high-grade distal small bowel obstruction.



The patient is transferred to the module and a surgery consult is placed. On reexamination, HR is 115, BP is 120/68. The patient is now nodding and shaking her head in response to questions. When asked if she has any pain, she indicates her abdomen. Her abdomen is still mildly distended and diffusely TTP without guarding or rebound.

A) What is the most likely cause of lactic acidosis in this patient?

  1. Increased pyruvate production
  2. Reduced entry of pyruvate into mitochondria
  3. Accumulation of NADH
  4. Impaired gluconeogenesis
  5. Metabolization of glucose by intestinal bacteria

B) What is the best fluid replacement option in this situation?

  1. Crystalloid (Normal Saline or Lactated Ringer)
  2. Buffer therapy (0.45% saline solution with 75mmol/L of sodium bicarbonate)
  3. Blood products
  4. Albumin
  5. Hyperoncotic starch

C) What further diagnostic studies, if any, are called for?

  1. No further studies are necessary
  2. Check patient’s D Dimer
  3. Check patient’s liver function; AST, ALT, Alk. phos.
  4. Abdominal CT angiogram
  5. Exploratory laparotomy

Filed under: Intern Report

Senior Report 8.11


Case Presentation by Alex Weissman, MD

Chief Complaint: “I feel terrible.”

History of Presenting Illness:
The patient is a 32-year-old female presenting with complaint of feeling “terrible and weak.” She states that this has happened to her twice in the last 24 hours. The first episode occurred upon awakening at 3 AM this morning with a sensation of doom, shortness of breath, chest pain, and in a cold sweat with chills. Subsequently she passed out. She ate some corn, felt better, and went back to sleep. Today, prior to arrival, the patient had another episode where she went into a cold sweat with chills and had a sensation of doom with chest pain and shortness of breath; however, this time she did not pass out. She called EMS, who found her capillary blood sugar was 32 mg/dL. The patient denies being sick recently. She denies insulin or sulfonylurea use. She denies abnormal stress in her life. She states that she has been eating normally. Last menstrual period was 3 years ago, the patient has always had irregular menses. The patient denies associated headache, sudden change in vision, abdominal pain, nausea, vomiting, diarrhea, constipation, dysuria, pain or numbness in the extremities, recent illness, or recent travel.

Review of System:
Constitutional: Complains of cold sweats and chills
HEENT: Denies headache
CVS: Complains of substernal chest pain
Lungs: Complains of SOB
Abdomen: Denies abdominal pain
Musculoskeletal: Denies pain in the extremities
Genitourinary: Denies dysuria
Skin: Denies rash
Neurologic: Denies numbness
Psychiatric: Denies depression


Past Medical History:
Bronchitis, splenomegaly, anemia, thrombocytopenia

Past Surgical History:
Bone marrow biopsy

Social History:
The patient denies use of tobacco, alcohol, or illicit drugs past or present.

Family Medical History:
Addison’s disease in her mother

Physical Exam:
Vitals: Blood pressure: 100/75, Pulse: 60, Respiratory rate: 18, Pulse Oximetry: Not initially recorded, Temperature: 36.2 degrees Celsius
General: Alert and oriented x3, no acute respiratory distress
Head: normocephalic, atraumatic
Eyes: PERRL, EOMI, bilateral conjunctival pallor, no scleral icterus
ENT: No cervical lymphadenopathy, no pharyngeal edema, mucous membranes moist
Cardiovascular: regular rate and rhythm, no appreciable murmurs, capillary refill <2 seconds
Respiratory: no tachypnea, no retractions, clear to ausculation bilaterally, no appreciable wheezes, rhonchi, or rales
Gastrointestinal: normoactive bowel sounds, nondistended, no tympany to percussion, soft and nontender to palpation
Musculoskeletal: Extremities are atraumatic, dorsalis pedis and radial pulses 2+ and regular bilaterally, no peripheral edema
Skin: no rashes or lesions
MENTAL STATUS: awake, alert, oriented
CRANIAL NERVES: face symmetric, pupils 3mm -> 2mm bilaterally, PERRL, EOMI, visual fields full to confrontation
MOTOR: patient moving all four extremities spontaneously, gait normal
SENSORY: intact to light touch




Initial CBG – 32 mg/dL


132 99 13 9.3 51
5.2 22 0.46 2.1

TSH: 3.586 Micro IU/mL


4.7 11.1 109

Serum pregnancy: negative
Insulin: <0.5 mcUnits/mL
Random cortisol: 2.2 mcg/dL



1) What are the classic physical exam and laboratory findings in primary adrenal insufficiency (Addison’s Disease)?
a) High blood pressure, high serum potassium, high serum sodium, low random cortisol, low serum glucose
b) Low blood pressure, high serum potassium, low serum sodium, low random cortisol, low serum glucose
c) High blood pressure, high serum potassium, low serum sodium, high random cortisol, high serum glucose
d) Low blood pressure, low serum potassium, low serum sodium, low random cortisol, low serum glucose

2) What laboratory test is used to diagnose adrenal insufficiency, what distinguishes primary versus secondary adrenal insufficiency, and what test value would you expect in primary adrenal insufficiency?
a) ACTH stimulating test; ACTH; low or normal ACTH level
b) Random cortisol; cortisol; low cortisol
c) ACTH stimulating test; ACTH; high ACTH level
d) Random cortisol; ACTH; low or normal ACTH level

3) What are some basic differences in symptomatology between primary and secondary adrenal deficiency?
a) Primary: Hypokalemia, hypernatremia, hypoglycemia, dehydration, hypotension, Cushingoid habitus
Secondary: Hyperkalemia, hyponatremia, normotension, hyperpigmentation, hyperglycemia

b) Primary: Hyperkalemia, hyponatremia, hypoglycemia, dehydration, hypotension, hyperpigmentation,
Secondary: Hypokalemia, hyper/hyponatremia, +/- Cushingoid habitus, hypoglycemia

c) Primary: Hypokalemia, hyponatremia, dehydration, hypotension, +/- Cushingoid habitus, hyperglycemia
Secondary: Hypernatremia, hyperkalemia, hyperpigmentation, normotension
d) Primary: Hyperkalemia, hyponatremia, hyperglycemia, normotension
Secondary: Hypokalemia, hypernatremia, hypoglycemia, hypotension, dehydration, hyperpigmentation, +/- Cushingoid     habitus


Bonus Question 1. What is the preferred steroid treatment for adrenal crisis and what vital sign abnormality should raise the ED physician’s clinical suspicion for an adrenal crisis?
a) Hydrocortisone – unexplained hypotension
b) Prednisone – unexplained hypertension
c) Dexamethasone – unexplained hypotension
d) Hydrocortisone – unexplained hypertension


Bonus question 2: What is the most common infectious cause of primary adrenal insufficiency in the US?
a) Tuberculosis
b) Meningitis
c) Influenza
d) HIV

Filed under: Senior Report, Uncategorized