CLINICAL CASES

CASE # 7

The correct answer is D. ITP is a disorder ofprimary immune platelet destruction. Theclinical presentation is of insidious onset ofmucocutaneous bleeding. The diagnosis is oneof exclusion; a complete blood cell count usuallyshows isolated thrombocytopenia, andlarge platelets may be apparent on peripheralsmear. Other tests may include a bone marrowbiopsy to exclude aplastic anemia or drug-inducedsuppression of megakaryocytes. In children,this disease is usually self-limiting and requiresno treatment, but adults generallyrequire medical (through immunosuppressionor dialysis) or surgical (through splenectomy)management. Children with chronic ITP haveplatelet counts from 20,000–75,000/mm³ andtypically do not require treatment. Pulse orshort-course corticosteroids may be used in refractorycases, but long-term daily steroid useshould be avoided.Answer A is incorrect. Corticosteroids are theinitial treatment of choice of ITP if the diseaseproves not to be self-limiting. Fifty to seventyfive percent of adults will respond, but <20%>

CASE # 6

A is the correct answer.
An infarct describes an area of tissue undergoing coagulative necrosis resulting from decreased blood supply. Embolization of a thrombus can occlude arterial vessels, resulting in infarcted tissue in various organs. Infarcts can be classified into either red (hemorrhagic) infarcts or white (pale) infarcts based upon their gross appearance on pathology. Red infarcts usually occur in loose tissues with collateral circulation or following reperfusion of the infarcted tissue. Pale infarcts usually occur in solid tissues with a single blood supply. Of the listed organs, only the kidney (choice A) has a single blood supply without collateral circulation.Liver (choice B), Lung (choice C), Small Intestine (choice D), and Large Intestine (choice E) all have more than one blood supply. An infarct in these tissues would tend to be grossly red on pathological examination.

CASE #5

the answer is:
A.Mycobacterium tuberculosis
Explanation:
This patient’s clinical features of chronic cough, weight loss, fever and malaise along with bilateral apical consolidation is typical for reactivation tuberculosis. A history of contact with a patient with tuberculosis is found in patients with primary pulmonary tuberculosis. Mycobacterial infection occurs early in the course of disease with CD4 counts greater than 200/microL.
Bacterial pneumonias usually present acutely with high fever, rigors and chest pain. Radiographic findings are usually segmental or lobar. CD4 counts are usually greater than 200/microL.
Clinical features of fever, dry cough and exertional dyspnea along with radiographic findings of diffuse bilateral interstitial infiltrates are typical of Pneumocystitis carinii pneumonia (PCP). PCP occurs with CD4 counts less than 200/microL. Presentation of PCP is subacute.
Histoplasma capsulatum infection is endemic in Mississippi and river valley areas. Disseminated fungal infection takes place when HIV infection is advanced and radiography usually shows a miliary pattern.
HHV-8 is considered the causative agent of Kaposi’s sarcoma, which usually has cutaneous findings and pulmonary involvement, which may be asymptomatic or mild. The chest x-ray usually shows a pulmonary nodule or pleural effusions.
Educational Objective:Tuberculosis occurs early in the course of HIV when the CD 4 counts are greater than 200/microL. Upper lobe consolidation and/or cavitation is the typical X-ray finding.

CASE #4

A 40-year-old white male patient develops proximal deep vein thrombosis of the left lower extremity. Detailed history, examination and lab testing fail to reveal any obvious cause or risk factor for deep venous thrombosis. Diagnosis of idiopathic deep vein thrombosis is made and it is decided that he will receive anticoagulation therapy with warfarin for 6 months. Which of the following is the therapeutic range of INR in this patient?
A.1.0 to 1.5
B.1.5 to 2.0
C.2.0 to 3.0
D.2.5 to 3.5
E.Greater than 4

Explanation:
INR (International Normalized Ratio) is used to monitor treatment response of warfarin.

Therapeutic range of INR varies according to the clinical situation. Therapeutic range of INR for most clinical situations is 2.0 to 3.0. These conditions include venous thromboembolism, valvular heart disease, and atrial fibrillation. A higher INR of 3.0 to 4.5 is required only in ceratin clinical settings like prosthetic heart valves. The risk of bleeding in patients treated with warfarin correlates with the degree of anticoagulation and it increases substantially when INR is greater than 4.
Educational Objective:Therapeutic INR for most clinical indications of warfarin is 2.0 to 3.0.

--

CASE#3

You are on rounds at the nursing home when you are asked to see an 83-year-old retiredfarmer who is bed-ridden. The aide is concerned because she has noticed an area on his coccyxthat is broken down. You examine the skin and determine that there is a partial thickness skinloss, which involves the epidermis. What stage is this pressure ulcer?

(A) Stage I (16%)

(B) Stage II (50%)

(C) Stage III (30%)

(D) Stage IV (16%)

The correct answer is (B) Stage IIThis patient has a stage II ulcer, which is a partial-thickness skin loss or ulceration that involvesthe epidermis, dermis, or both layers.

A stage I ulcer is defined as intact skin that has a change in temperature, consistency, sensation,or color. The temperature can be warm or cool; the consistency can be firm or boggy; the patientmay experience pain or itching; the color may be red, blue, or purple.

A stage III ulcer is a fullthicknessskin loss, with evidence of damage to or necrosis of subcutaneous tissue, which mayextend to, but not through, the underlying muscle.

A stage IV ulcer involves full-thickness skinloss with destruction, tissue necrosis, or damage to underlying muscle, bone, or supportingstructures.

CASE#2

21-year-old man, who was recently diagnosed with asthma, comes to see his primary care physician. The patient says that he has about two episodes of shortness of breath per week. He reports no symptoms of asthma at night. Vital signs are: temperature 36.9 C (98.4 F), pulse 78/min, blood pressure 118/66 mmHg, respiration 16/min, and oxygen saturation 96% on room air. Physical examination reveals a well-developed young man in no distress. Breath sound are clear bilaterally. Heart sound are normal with no murmur. Abdomen is soft and nontender, with normoactive bowel sound. Pulmonary function testing shows FEV1/FVC 86% of predicted. Which of the following is the most appropriate next step in management?
A. Albuterol.

B. Flunisolid.

C. Formoterol.

D. Prednisone.

E. Theophylline.

The correct answer is A. this patient has mild intermittent asthma, which is characterized by asthma symptoms occurring twice a week or less, no symptoms between exacerbation, night symptoms occurring no more than twice a month, and a FEV1/FVC that is 80% or more of predicted. Patients with mild intermitten asthma are treated with intermitten use of inhaled short-acting beta-2-agonist, like albuterol.

Flunisolid (B) is an inhaled corticosteroid, which is mainly used for persistent asthma. Inhaled corticosteroid reduce inflammation in asthma and are very safe drugs with little if any effect on the pituitary-adrenal axis.

Formoterol (C) is a long-acting, inhaled beta-agonist. It is used for moderate to sever asthma.
Prednisone (D) is an oral corticosteroid, which is only used for treatment of sever persistent asthma.
Theophylline (E) has bronchodilator effect and inflammatory activity. Once the mainstay of asthma treatment, it is now considered a third-line or even fourth-line agent because of its adverse-effect profile and potential interactions with many drugs.

CASE #1

A 34-year-old man presents to the clinic, 24 hours after he was hit in the abdomen. He has had constant abdominal pain since the altercation. He denies nausea and vomiting. His abdomen is soft, painful to palpation mostly around the umbilicus. Rebound tenderness is also present. Bowel sounds are diminished. Rectal exam is normal. Abdominal x-ray, ultrasonogram (USG), and CT are unremarkable. His vitals are, BP: 120/70mm of Hg; PR: 90/min; Hct: 40%; serum Amylase: 53 U/L. Most appropriate management is:

A. Observation

B. Angiography

C. Contrast studies of GI tract

D. Diagnostic peritoneal lavage

E. Laparotomy

answer is D

Explanation:
Major splenic and liver lacerations, bowel avulsion, and vascular tears produce significant blood loss and are unlikely in this patient because his Hct and vital signs are normal. Subcapsular splenic and liver hematomas that can produce delayed bleeding are currently excluded by the normal US and CT. Therefore he doesn’t have clear indications for laparotomy (Choice E).

He may have however, other serious traumatic lesions. Small lacerations of solid organs, mesentery, and in the serosa of the hollow viscus may give little bleeding that may stop spontaneously. In such cases intraperitoneal fluid may not be detected on USG. Small perforations of the hollow viscus may not produce gas under the diaphragm on x-ray, but still causing peritonitis. Diagnostic peritoneal lavage is the simplest method to check for these pathologies. If it is negative, the patient may be followed with observation (Choice A).

Diagnostic peritoneal lavage would be more informative than contrast studies of GI tract for this patient.

Angiography is rarely performed for abdominal trauma, as laparotomy is usually preferred.