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Dr. Juan Carlo

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CLINICAL CASES

CASOS CLÍNICOS

Dr. Juan Carlos Díaz TorrePediatra Neonatólogo dr_diaz_torre@hotmail.com(779) 100 - 40 - 26

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Dr. Juan Carlo

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Page 223

A 42 year old male comes in with a history of recurrent episodes of hives over the past 5 day that are intensely pruritic on the arms, chest, and back. He has a medical histoy of Diabetes Type II, coronary artery disease and a recent urinary tract infection. His medications

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Dr. Juan Carlo

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include glucophage, lisinopril, baby aspirin and trimethoprim – sulfamethoxazole. He has applied over the counter Calamine lotion and has been taking Benadryl without much relief. He denies any new use of soaps or products and has not been out of the country recently. He is not in contact with any plants or chemicals at work.

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Dr. Juan Carlo

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Question:What is the mechanism of hypersensitivity in this case.

Answers:a) Overabundance of IgA.b) Overabundance IgG.c) Prostanglandin synthesis.d) Mas cell degranulation.

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Dr. Juan Carlo

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Page 210

A 75 years old female is evaluated for refux esophagitis. At endoscopy the mucosa is salmon pink with a definite demarcation between normal and abnormal esophageal mucosa. Biopsy indicates no dysplasia. Three weeks following a Nissen Fundoplication, the

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Dr. Juan Carlo

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patient has a severe episode of retching following a heavy meal and has been vomiting with blodd. Two hours later, he has severe epigastric pain and a spiking temperature of 102 F.

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Dr. Juan Carlo

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Question:Which of the following is the problem?

Answers:a) The Nissen has slipped.b) Fundoplication disruption has

occurred with perforation.c) A perforated ulcer has developed.d) Acute pancreatitis.

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Dr. Juan Carlo

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Page 222

A 76 year old black male with a history of chronic gout, on uric acid lowering therapy and severe Class IV renal disease presents with multiple swollen joints. Aspiration of his knee reveals uric acid crystals intracellularly.

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Dr. Juan Carlo

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Question:What is the most appropriate therapy for him a this time?

Answers:a) Start indomethacin.b) Start prednisone.c) Discontinue allopurinol.d) Start febuxastat.

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Dr. Juan Carlo

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Page 215

A 48 year old man presents with hemoptysis. He reports that he has also had bloody nasal discharge over the past month. His CXR shows bilateral nodules. Laboratory data is notable for creatinine of 4.7 mg/dl, and urine analysis shows 250 RBC/hpf.

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Dr. Juan Carlo

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Question:Which of the following serum studies should be ordered next?

Answers:a) ANCA, anti-GBM antibodies. (AntiNuclear Cytoplamic Antibodies, Glomerular Basement Membrane Antibodies)

b) Anti-dis-DNA and anti-cardiolipin antibodies.C) ESR, C3, C4 levels.D) RF, anti-citrulline antibodies.

(Rheumatoid Factor)

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Dr. Juan Carlo

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Page 211

A 46 year old male has had intermittent flares of ulcerative pancolitis for 10 years. He has increasing diarrhea, blood per rectum, and fever. He responds to medical management.

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Dr. Juan Carlo

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Question:Proctocolectomy is indicated for?

Answers:a) Length of colon involved.b) Long periods of persistent disease.c) Severe dysplasia on initial biopsy.d) Persistent stricture.

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Dr. Juan Carlo

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Page 218

A 46 year old woman with a history of asthma calls you for a refill of her albuterol inhaler. Her asthma has always been well-controlled on a daily dose of moderate-dose inhaled corticosteroid and she´s long misplaced her albuterol inhaler. However 3 weeks ago she had an upper respiratory tract infection.

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Dr. Juan Carlo

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All her acute symptoms have resolved but since then she has felt more wheezing, and often coughs at night. She’s been using her daughter’s albuterol inhaler and finally decides to call you to get her own prescription.

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Dr. Juan Carlo

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Question:What is the next appropriate step in management?

Answers:a) Prescribe a course of oral

fluoroquinolone.b) Prescribe albuterol inhaler for as

needed rescue use.

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Dr. Juan Carlo

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c) A short course of oral corticosteroid therapy.

d) Double her moderate-dose inhaled corticosteroid therapy.

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Dr. Juan Carlo

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Page 212

A 75 year old woman suffered from sudden onset left eye blindness. No pain was associated with her blindness, and no other abnormalities were seen in the neurological examination.

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Dr. Juan Carlo

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Question:What is the most likely diagnosis?

Answers:a) Small lacunar stroke involving the

occipital lobe.b) Ischemic lesion involving the lateral

geniculate nucleus.

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Dr. Juan Carlo

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a) Compressive lesion on the optical chiasm.

b) Retinal ischemia due to retinal artery occlusion.

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Dr. Juan Carlo

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Page 213

A 25 year old man with HIV presented to the ED with right-sided weakness and confusion. An MRI of the brain showed a few ring enhancing lesions. The differential diagnosisis narrowed to toxopasmosis and primary CNS lymphoma.

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Dr. Juan Carlo

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Question:What is the appropriate next step management?

Answers:a) Open brain biopsy.b) Stereotactic brain biopsy.c) Empiric treatment of toxoplasmosis

with reimagining to evaluate the response.

d) High dose steroids.

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Dr. Juan Carlo

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Page 215

A 65 year old male with pneumonia and septic shock develops acute kidney injury. He has been running a low blood pressure (80/45 mmHg) on several vasopressor agents. Urine output start to fall and his creatinine begins to rise. His urine sodium is high; he has no proteinuria.

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Dr. Juan Carlo

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Question:The most common cause of his kidney failure in this setting is:

Answers:a) Obstruction.b) Acute tubular necrosis.c) Acute interstitial nephritis.d) Goodpasture´s disease.

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Dr. Juan Carlo

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Page 220

A 32 year old white female with systemic lupus erythematosus is 32 weeks pregnant and presents to your office with a headache. Physical examination is remarkable for a blood pressure of 200/110 mmHg. Laboratory studies show a hemoglobin of 8.0 g/dl, platelet count of 38,000, a low haptoglobin level, and an elevated LDH, AST and ALT.

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Dr. Juan Carlo

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Question:What test should be best to determine the cause of her problems?

Answers:a) Complement levels.b) Erythrocyte sedimentation rate.c) Anti-Smith antibody.d) C-reactive protein.

DR.

JCDT

Dr. Juan Carlo

s Díaz T

orreGracias por su atención

Dr. Juan Carlos Díaz Torre Pediatra Neonatólogo

dr_diaz_torre@hotmail.com(779) 100 - 40 - 26

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