clinical cases april 7,13
TRANSCRIPT
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
CLINICAL CASES
CASOS CLÍNICOS
Dr. Juan Carlos Díaz TorrePediatra Neonatólogo [email protected](779) 100 - 40 - 26
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DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
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Page 222
A 69 year old morbidly obese white female states that she has severe disabling right knee pain.
The pain has been ongoing for the past two weeks and has been keeping her awake at night.
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
3
She does not recall any preceding trauma and has been using a pillow between her kness with some benefit.
Physical examination reveals crepitus and mild tenderness of the knee with severe pain 4 cm below the medial joint line.
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
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Question:
What is the most appropriate next step?
Answers:a) X ray of the knee.b) MRI of the knee.c) Corticosteoid injectiond) Local supportive therapies.
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
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Page 217
A 60 year old man with severe COPD is found to be difficult to arouse after undergoing an outpatient, elective screening colonoscopy. The following lab data are available: ABG on room air pH 7.24, PaO2 64, PaCO2 78, Electrolytes: Na 140, HCO3 35, Cl 100.
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
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Question:What is his current acid-base status?
Answers:a) Metabolic acidosis with respiratory
compensation.b) Acute respiratory acidosis with
metabolic compensation.c) Acute on chronic respiratory
acidosis.d) Chronic acidosis with metabolic
compensation.
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
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Page 212
A 51 year old male started to have a gradual decline in his intellectual functions associated with depressive symptoms and personality changes. The patient obtained a score of 23/30 on mini-mental status examination and on physical examination chorea was noted. The diagnosis of Huntington’s disease was suspected.
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
8
Question:
What is typical inheritance pattern of Huntington’s disease?
Answers:a) X- linked.b) Autosomal dominant.c) Autosomal recessive.d) No familial pattern.
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
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Page 220
A 24 year old female has diagnosed Systemic Lupus Erythematosus for the past 5 years. She has had episodes of discoid rashes as well as polyarthritis and mild hematologic abnormalities, but none in the past year.
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
10
Question:
What pharmacological agent would be most appropiate for her?
a) Prednisone.b) Hydrocloroquine.c) Cyclophosphamide.d) Metrotexate.
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
11
Page 221
A 29 year old male has lower back pain without radiation for the past 3 weeks. He does not recall any specific instigating event. Pain is severe and worse with sitting, as well as standing. His neurological examinations is unremarkable.
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
12
Question:
Which of the following is the most appropriate action at this time?
Answers:a) Check x-ray of his lower back.b) Check an MRI of his lower back.c) Start physical therapy and NSAID’s.d) An EMG evaluation of his lower
extremities.
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
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Page 219
A 30 year old patient with Sjogren´s syndrome is placed on a cytotoxic agent as well as oral steroids. At 3 months she begins tl have right thigh and knee pain that is increased with walking and standing. Physical examination reveals normal range of motion of her knee, but mild pain on internal and external rotation of her hip.
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
14
Question:
What is the most sensitive and appropiate test to diagnose his condition early?
Answer:a) Plain film radiography.b) Technetium-99m bone scanning.c) Magnetic resonance imaging.d) CT scan.
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
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Page 218
A 52 year old Hispanic female is seen in consultation in the hospital. She states that she has had a complete physical with laboratory testing 2 months earlier that was completely normal.She feels poorly now for the past few weeks. Her legs have become swollen and she is having shortness of breath.
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
16
Laboratory testing reveals a positive ANA1:360, an elevated ds-DNA, low C3 and C4 levels, a 24 urine protein of 2.5 grams with significant RBCs on her urinalysis, and renal failure. An echocardiogram shows a significant pericardial effusion, but no evidence of tamponade. A kidney biopsy reveals diffuse proliferative lupus nephritis.
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
17
Question:
Which of tje following is the most appropiate therapy at this time?
a) Cyclophosphamide.b) Azothioprine.c) Solumedrol.d) Plasmaferesis.
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
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Page 218
A 48 year old man presents with a week of fever, cough, and malaise. He has no significant past medical history and he takes no medications. His vital signs are normal but an exam reveals right side crackles. A CXR shows a right lower lobe infiltrate.
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
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Question:
What antibiotic should be started?
a) Doxycycline.b) Trimethoprim/Sulfametoxazole.c) Cephalexine.d) Amoxicilline/Clavulanate.
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
20
Page 216
A 38 year old woman with a history of asthma has had multiple admissions in the past year for asthma exacerbation. She was treated during the most recent hospitalization for a community acquired pneumonia that was seen on CXR. She comes to you for post-discharge follow up.
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
21
She reports she is compliant with her combination steroid/long-acting beta agonist inhaler, but still needs her rescue inhaler several times a day, and still has a cough occasionally productive of brown plug.Her blood work on the day of discharge was only significant for an eosinophilic count of 750/mm3.
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
22
Question:
Which of the following should be considered?
a) Chronic eosinophilic pneumonia.b) Allergic broncopulmonary aspergillosis.c) Steroid non responsive asthma.d) Viral bronchitis.
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
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Page 213
A 32 year old primigravida presents to her obstetrician for routine follow up at 34 weeks gestation. She has a sonogram of the developing baby which also shows that she has developed right sided moderate hydronephrosis. Serum creatinine concentration is checked and is 0.8 mg/dl.She has no symptoms. Urinalysis is normal.
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
24
Question:
At this point you should:
Answer:a) Send urine for culture assuming
infection.b) Consult Urology immediately.c) Admit to the hospital.d) No further intervention.
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orreGracias por su atención
Dr. Juan Carlos Díaz Torre Pediatra Neonatólogo
[email protected](779) 100 - 40 - 26
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