all case studies exam 2

A 55-year-old man presents to the emergency room with intense pain in the back, abdomen, and groin. He was brought by ambulance after feeling nauseated and suddenly fainting. On physical examination, he is pale, sweating profusely, and hypotensive. You also note a pulsatile mass in the mid-abdomen. As you begin to give the patient fluids and prepare him for emergency imaging, you call for a vascular surgery consult to evaluate this patient for surgery.

Aortic aneurysm

A 33-year-old man with Down syndrome presents to your clinic with gradual onset of shortness of breath over the last several months. Physical examination reveals a systolic flow murmur at the left upper sternal border, a widely fixed split S2 sound, and an oxygen saturation level of 93% on room air. As you schedule the patient for several cardiac tests, you worry that he may need surgery to correct his condition.

Atrial septal defect- Ostium primum

A 2-year-old girl is brought to your pediatric cardiology clinic for evaluation of a murmur heard by her primary care doctor. In speaking with the girl's father, he tells you that she is healthy and active. On physical examination, you note that the girl is well nourished and appropriately sized for her age. You do detect a loud, harsh, holosystolic murmur at the left lower sternal border, with no evidence of right ventricular strain. You suspect that the child has the most common congenital cardiac anomaly and you order an echocardiogram to confirm your suspicions. In the meantime, you reassure the girl's father that her anomaly is likely minor and will require no treatment.

Ventricular septal defect

A newborn boy, born to a diabetic mother, is found to be blue. Physical examination reveals a holosystolic murmur, consistent with the presence of a large VSD. A CXR demonstrates a boot-shaped heart. As you schedule several cardiac tests for the baby, you suspect that the child will most certainly need surgery to correct the myriad of defects associated with his condition.

Tetralogy of Fallot

During a routine physical examination, a 60-year-old man mentions to you that he occasionally experiences chest discomfort that radiates to his left shoulder. He describes that discomfort as a "weight on his chest" and notes that the pain tends to come on after he shovels his driveway and dissipates with rest. He denies any chest pain at rest. You schedule him for an exercise stress test, write him a prescription for nitroglycerin, and warn him against performing any strenuous exercise until further consultation with a cardiologist

Angina pectoris/Prinzmetal angina/Stable angina/Unstable angina

A 72 yr old female presents to the emergency department complaining of 2 hours of crushing substernal chest pain. She is breathing heavily and sweating profusely. You orde3r an ECG, which demonstrates ST elevations across the precordium. You immediately activate the cardiac cath lab in the hopes of minimizing tissue damage caused by her condition.

ST-Elevation Myocardial Infarction

An 82 yr old male presents to the ER with weakness and fever. Hypotensive with blood pressure of 80/60. Urinalysis is positive for nitrites and leukocyte esterase as well as elevated troponin I of 0.12. ECG within normal limits. Suffered a cardiac event

Non-ST-elevation Myocardial Infarction

A 23-year-old woman presents to your primary care clinic for establishment of care. She notes that she has developed increasing dyspnea on exertion over the last 6 months as well as lower extremity swelling. She has no significant past medical history, although she does recall having had strep throat 10 years ago, which was not treated with antibiotics. On physical examination, you hear a late, low-frequency, rumbling, mid-diastolic murmur following a high-pitched opening snap heard best at the apex of the heart. You order an echocardiogram and refer her to a cardiologist for further treatment of her condition

Chronic Rheumatic heart disease

A 10-year-old girl presents to the clinic with fever, malaise, migratory polyarthritis, and a blanching erythematous ring-shaped rash over her proximal extremities. On further questioning, you find out that she suffered from a severe sore throat 2 to 3 weeks ago. Serum studies demonstrate an ESR of 100 mm/h and a positive anti-streptolysin O (ASO) titer. You worry that she may suffer from valvular heart disease during her adult years as a result of her current condition

Acute rheumatic fever/Rheumatic heart disease

A 30-year-old man presents to the emergency room with sudden high fever and shaking chills. A new murmur localized to the mitral valve is heard. The patient has bilateral nail-bed hemorrhages, painful nodules on the tips of his fingers and toes, an erythematous rash on his palms and soles, and white spots surrounded by hemorrhage in his retina. You immediately begin the patient on broad-spectrum antibiotics and order blood cultures and an echocardiogram to confirm the diagnosis

Acute Endocarditis

A 20-year-old man from Panama presents to your clinic complaining of dyspnea, orthopnea, bilateral leg swelling, and a bloated belly. He denies any history of a congenital heart disease, rheumatic fever, or valvular disease. An echocardiogram demonstrates biventricular failure. As you prepare to admit him to the hospital for further testing and treatment, you wonder if a parasitic disease endemic to his native country may be causing his condition.

Myocarditis

A 72-year-old man presents to the emergency room with difficulty breathing. He is visiting from out-of-town to celebrate his granddaughter's high school graduation. He states that the whole family has been celebrating over the last 5 days, eating out a lot and drinking alcohol. In addition to his dietary indiscretions, he admits to forgetting to take some of his medications. His past medical history is significant for two prior heart attacks and a "weak heart." On physical examination, you note that the patient is hypertensive with a BP of 170/100 mm Hg and mildly tachycardic with an HR of 100 beats/min. His lungs have crackles throughout and he has significant pitting edema in bilateral lower extremities. An ECG shows no evidence of an acute MI. You begin to suspect that the patient is suffering from an exacerbation of a chronic weakness of heart muscle, which was most likely caused by his prior heart attacks.

Dilated Cardiomyopathy

A 20-year-old college football player suddenly collapses and dies during a practice session. His father had suffered a similar fate in his early 30s. On autopsy, he is found to have a hypertrophied heart with an enlarged intraventricular septum. On histologic examination of the myocardium, you see disoriented, tangled, hypertrophied myocardial fibers and you suspect that his death was related to an autosomal dominant condition, resulting in a mutation of β-myosin heavy-chain protein gene.

Hypertrophic cardiomyopathy

A 58-year-old woman presents to your cardiology clinic for evaluation of dyspnea. She reports that over the last 6 months, she has become progressively short of breath with activity. She has also begun to notice swelling of both her legs. Physical examination is notable for bilateral crackles in the lung fields as well as pitting edema in bilateral lower extremities. You order an echo-cardiogram, which reveals a thickened heart with evidence of decreased ventricular compliance and impaired diastolic filling. You tell the patient that she has a serious condition and that she will need further testing to see if an underlying cause for her condition can be identified.

Restrictive cardiomyopathy

A 75-year-old woman with a history of metastatic breast cancer presents to the emergency department complaining of weakness and difficulty breathing. On physical examination, her blood pressure is 90/50 mm Hg and her heart sounds are distant and faint. You also note that she has an increased JVP. When an ECG reveals a QRS complex height that varies from one heart beat to the next, you prepare for an immediate pericardiocentesis.

Cardiac tamponade

A 55-year-old woman presents to your clinic complaining of ankle swelling and increasing shortness of breath with exertion. Upon directed questioning, she reveals that she also experiences shortness of breath when she is lying down. Physical examination reveals marked hepatosplenomegaly, distended neck veins, and pedal edema. A CXR is suggestive of cardiomegaly. You start the patient on an ACE inhibitor, diuretic, and a low-sodium diet, and you refer her to a cardiologist for further workup of her condition.

Congestive heart failure/Right Sided

A 63-year-old man presents to your office complaining of worsening shortness of breath over the past year. You know that this patient has smoked two packs of cigarettes a day for the past 45 years. As you are talking to the patient, you notice that he is using his accessory muscles of respiration to breathe, that his chest is barrel shaped, and that he is breathing carefully through pursed lips. Using a spirometer, you determine that he has a decreased FEV1/FVC ratio and an increased TLC. You tell the patient that it is imperative that he stop smoking and prescribe him a tiotropium inhaler.

Emphysema

An 8-year-old girl is brought into an urgent-care clinic complaining of shortness of breath. Her past medical history is significant for multiple allergies. Upon physical examination, you hear expiratory wheezes and you observe that the patient is using her accessory muscles of respiration. You decide to administer an inhaled β2-adrenergic agonist for relief of her symptoms.

Asthma

A 74-year-old man presents to your office complaining of a persistent cough, which is productive of copious sputum. He admits that he is a heavy smoker and has suffered from similar coughs for several years. Physical examination reveals diffuse wheezing and crackles. You suspect that this patient will have a decreased FEV1/FVC ratio and strongly suggest that he stop smoking

Chronic bronchitis

A 2-year-old girl is brought to the emergency department because of shortness of breath and a productive cough. Upon questioning her parents, you discover that this patient has a history of pulmonary infections and bulky stools that float. Physical examination reveals a thin girl with a barrel-shaped chest, crackles over both lungs, and digital clubbing. Later, a sweat test demonstrates high levels of chloride ions. You realize that this girl will have a severely shortened life span owing to her condition.

Cystic fibrosis

A 49-year-old man presents to your clinic complaining of mild shortness of breath over the past year. He does not smoke, although he has worked in a glass-manufacturing factory for over 20 years. A CXR reveals eggshell calcification of the hilar lymph nodes. You make a diagnosis and suggest that he have a PPD placed because his condition is associated with increased susceptibility to TB.

Anthracosis/Coal worker pneumoconioses/Pneumoconioses/Silicosis

A 63-year-old man is hospitalized for a severe case of lobar pneumonia with sepsis. Within the first 24 hours of his hospitalization, he develops worsening respiratory failure and requires intubation. A CXR reveals bilateral patchy opacities. He becomes progressively hypoxemic even with increased oxygen delivery via the ventilator. You continue to treat the patient's pneumonia, but you worry that he will have up a 30%-60% mortality rate given his current condition.

Acute respiratory distress syndrome/Neonatal respiratory distress syndrome

A 59-year-old man presents to your office with a productive cough and dyspnea. He has smoked heavily for many years and works in construction. A CT scan reveals interstitial lung fibrosis and calcified pleural plaques. You inform him that his condition has placed him at great risk for both bronchogenic carcinoma and malignant mesothelioma of the pleura.

Asbestosis

A 64-year-old woman presents to your rural primary-care office complaining of progressive dyspnea over the past 6-8 months. She also tells you that she has lost 12 lb in the last 3 months. A detailed history reveals that the patient is a dairy farmer. Physical examination is notable for bibasilar crackles. A high-resolution CT scan reveals ground glass abnormalities and interstitial fibrosis predominantly in the upper lobes of bilateral lungs. You begin to suspect that her symptoms are related to chronic exposure to a substance related to her livelihood.

Farmer's lung/Hypersensitivity pneumonitis

A 32-year-old African American woman presents to the urgent-care clinic complaining of fever, rash, and dyspnea. Upon questioning her further, you discover that she has been suffering from arthralgias in both her knees and her right hip. Physical examination is notable for a red, nodular rash on all of her extremities. A CXR reveals interstitial lung infiltrates and massive bilateral hilar lymphadenopathy. Laboratory testing reveals an increased ESR, increased ACE activity, and hypercalciuria. You suspect that you will see noncaseating granulomas on a biopsy of her hilar lymph nodes

Sarcoidosis

An 82-year-old woman presents to the emergency department complaining of severe shortness of breath. She tells you that her right calf has been sore as well. On directed history, you discover that she suffered a stroke 6 months ago and has been bedridden ever since. Further evaluation reveals that she is hypoxic and has elevated D-dimer levels. You decide to begin empiric anticoagulant therapy and you order a high-resolution CT scan of the chest with contrast.

Pulmonary embolism/Virchow triad

A 68-year-old man presents to the emergency department complaining of a fever, dyspnea, and a cough productive of green sputum. Physical examination reveals an ill-appearing man, breathing heavily. On lung examination, you note bronchial breath sounds and dullness to percussion over the right lower lung lobe. A CXR demonstrates circumscribed opacity over the region of his right lower lung lobe. You obtain sputum and blood cultures and then admit this patient to the hospital for antibiotic treatment.

Acute bacterial pneumonia

A 21-year-old woman presents to the university health clinic complaining of general weakness and a low-grade fever of 3 days' duration. Upon directed history, you learn that she has had an occasional cough and dyspnea and that her two roommates have been suffering from similar symptoms. When a CXR reveals patchy infiltrates, you prescribe her a course of azithromycin and schedule her for a follow-up visit to make sure that her symptoms have resolved.

Atypical pneumonia

A 42-year-old HIV-positive man presents to the emergency department with hemoptysis. He states that he has lost 15 lb over the last 2 months and has had an intermittent fever, cough, and chills. He has not been taking any of his HIV medications and his CD4 count is 130. A CXR reveals a lesion in his apical right lung. He is able to cough up green mucous coated with blood. You send the sample off for staining and culture. The sample reveals acid-fast bacilli, and you decide to admit this patient to an isolation room and begin him on a multidrug treatment regimen while drug susceptibility tests are run.

Tuberculosis

A 26-year-old pregnant woman presents to your office for a checkup. She states that her pregnancy has been proceeding smoothly, although she has been feeling more tired than she expected. Her physical examination is largely unremarkable except for marked pallor. You order serum studies and find that she has decreased hematocrit, decreased ferritin, and increased TIBC. Her peripheral blood smear shows RBCs that are both microcytic and hypochromic. You reassure her that these findings are most likely associated with her pregnancy status and you recommend that she start taking iron supplements

Iron-deficiency anemia/

A 46-year-old man presents to your office complaining of weakness and a "pins and needles" feeling in his extremities. You note that he is ataxic and has decreased vibration and position sense in both his arms and legs. Upon further examination, you also observe that his tongue is red and enlarged. When laboratory tests reveal a positive Schilling test and a macrocytic anemia, you question the patient's diet habits, drinking habits, and history of abdominal surgery.

Megaloblastic anemias

Pernicious anemia/Vitamin B12 deficiency anemia/Folate deficiency anemia

An 8-year-old African American boy presents to the emergency department complaining of severe pain in both legs. The pain began after the boy attended a pool party and spent much of the day swimming. He reports that he has suffered from severe bouts of back and chest pain in the past owing to a preexisting medical condition. Routine laboratory studies demonstrate a severe anemia. You place the child on oxygen, begin aggressive intravenous fluid hydration, and call the blood bank to prepare for a blood transfusion.

Sickle cell anemia

A 10-month-old male infant from Greece presents with pallor and failure to thrive. During physical examination, you find that his spleen is enlarged and that he has an abnormal facial structure. You order a peripheral blood smear, which shows a microcytic, hypochromic anemia with target cells. You begin to suspect that this child may need blood transfusions for the rest of his life.

Thalassemias

A 15-year-old adolescent girl presents to the emergency department with a petechial rash, bleeding of the oral mucosa, fatigue, and a history of recurrent sinus infections over the past 2 months. She does remember having had a bad flu-like virus about 3 months ago that caused her to miss 4 days of school. There is no hepatosplenomegaly on examination. Laboratory tests reveal anemia, neutropenia, and thrombocytopenia. There are no abnormal cell types seen on peripheral blood smear. You decide to admit the patient to the hospital and you schedule a bone marrow biopsy.

Aplastic anemia

A 30-year-old woman arrives at the emergency room complaining of fatigue and dark-colored urine. While obtaining the history of her present illness, you learn that she has been recovering from a recent bout of atypical pneumonia, for which she had been treated appropriately by her primary care physician with a course of antibiotics. Physical examination reveals an enlarged spleen and slight scleral icterus. When blood tests reveal an elevated LDH, elevated indirect bilirubin level, and decreased hematocrit, you begin to wonder if a direct Coombs test will confirm your suspected diagnosis.

Autoimmune hemolytic anemias/Cold agglutinin disease/Warm antibody autoimmune hemolytic anemia

A 6-year-old boy presents to your office complaining of fatigue, fever, and a history of recurrent epistaxis (nose bleeds) and UTIs. He is remarkably pale and has a petechial rash over his entire body. Concerned, you send him for some blood tests, which demonstrate pancytopenia with the presence of multiple blast forms. You fear that a bone marrow biopsy may demonstrate cells that would stain positive for TdT and CALLA.

Acute lymphoblastic leukemia

A 52-year-old woman presents to your clinic complaining of a 2-week history of low-grade fever and weakness. Further evaluation reveals that she has suffered from various infections over the past 3 months. Upon physical examination, you note that she is pale with a petechial rash and that she has an enlarged spleen and liver. After a peripheral blood smear demonstrates pancytopenia with multiple myeloblasts, you immediately refer this patient to a hematologist/oncologist

Acute myelogenous leukemia

A 55-year-old man presents to your office complaining of a feeling of heaviness in his abdomen. He has had several infections over the past 6 months. Physical examination demonstrates a massively enlarged spleen and a peripheral blood smear reveals abnormal cells with filamentous projections. As you refer this patient to a hematologist/oncologist, you reassure him that his disease is very sensitive to treatment.

Hairy cell leukemia

A 44-year-old man presents to your clinic complaining of severe fatigue. Physical examination is relatively unremarkable except for an enlarged spleen. You send him to the laboratory for blood tests, which reveal multiple immature granulocytes on peripheral blood smear, a high WBC count, and low LAP activity. Based on these test results, you begin to suspect that he may have a chromosomal abnormality.

Chronic myelogenous leukemia

A 22-year-old man presents to your office complaining of a painless lump in his neck. Upon further questioning, you discover that he has had a low-grade fever and drenching night sweats for the past 2 months. He also has lost 14 lb over the past 8 weeks. Physical examination reveals unilateral cervical lymphadenopathy and splenomegaly. A lymph node biopsy reveals large multinucleated cells with prominent nucleoli resembling owl's eyes. You immediately refer the patient to a hematologist/oncologist.

Hodgkin lymphoma

A 57-year-old man presents to your office after noticing a large painless lump in his neck. Upon questioning, he tells you that he has been suffering from a low-grade fever over the past 3 months. He has also lost 10 lb during that time. Physical examination reveals painless cervical and inguinal lymphadenopathy and hepatosplenomegaly. Blood tests reveal a mild anemia as well as elevated LDH levels. You decide to send him for a lymph node biopsy.

Non-Hodgkin lymphoma

Burkitt lymphoma/Diffuse large B-cell lymphoma/Follicular lymphoma

An 18 yr old male presents to your primary care clinic for evaluation of jaw swelling and pain. he denies any recent trauma to the area and reports good dental care. he recently moved to the US from Africa. further history is notable for night sweats over past several months. Physical examination demonstrates and osteolytic lesion in the jaw, you begin to wonder if a biopsy of the mass will demonstrate a classic starry-sky appearance of cells

Non-Hodgkin lymphoma B/ Burkitt Lymphoma

A 69-year-old man presents to the emergency department complaining of pain in his neck and back. Upon directed history, he also reveals that he has been extremely tired and has suffered from two UTIs over the past 4 months. An x-ray of his back reveals fractures in the L2 and L3 vertebrae as well as punched-out lytic bone lesions in the posterior skull. Laboratory studies reveal a mild anemia as well as an elevated BUN and creatinine. You decide to admit him to the hematology/oncology service for further evaluation.

Multiple myeloma

An 8-year-old boy presents to the emergency department with a swollen right knee. He denies a history of trauma to the knee. Physical examination reveals a warm, swollen, erythematous joint with a significant effusion. Upon taking a family history, you learn that two of the boy's maternal uncles suffer from a bleeding disorder. Laboratory tests reveal a prolonged PTT, a normal PT, and a normal bleeding time. To provide the proper treatment, you immediately order a clotting factor assay.

Hemophilia A/Hemophilia B deficiency