clinical cases (1) june 30, 13

Dr. Juan Carlo

s Díaz T

CURSO DE INGLÉS

ENGLISH COURSE

Dr. Juan Carlos Díaz TorrePediatra Neonatólogodr_diaz_torre@hotmail.com

(779) 100 - 40 - 26

Dr. Juan Carlo

s Díaz T

BRIEF CLINICAL CASES CASOS CLÍNICOS BREVES

Dr. Juan Carlos Díaz Torre

Pediatra Neonatólogodr_diaz_torre@hotmail.com

(779) 100 - 40 - 26

Dr. Juan Carlo

s Díaz T

Case # 161

A 58-year-old male who works with heavy machinery at a local factory presents to your office for evaluation of hearing loss of several years’ progression. He notes that the loss is mainly in the left ear and he also has mild tinnitus. He has had no trauma to his head, and he has no history of ear infections.

Dr. Juan Carlo

s Díaz T

Examination of the ears reveals normal tympanic membranes and a neurologic examination is negative. When a tuning fork is placed in the center of his forehead, he says the sound is much louder on the right side (Weber test). Comparing sound in front of the ear to the sound when the tuning fork is placed on the mastoid (the Rinne test) reveals that air conduction is better than bone conduction in the left ear.

Dr. Juan Carlo

s Díaz T

Which one of the following is true regarding further evaluation and management? :

a) Carotid ultrasonography should be ordered

b) No treatment or further diagnostic studies are indicated

Dr. Juan Carlo

s Díaz T

c) A hearing aid plus better hearing protection is all that is needed

d) Audiometry is the best initial screening test

e) A tympanogram is indicated

Dr. Juan Carlo

s Díaz T

Case # 162

A 6-year-old male is brought to your office 10 days after the onset of a cough and low-grade fever.On examination, his temperature is 37.9° C (100.2° F), pulse 100 beats/min, respirations 22/min, and O2 saturation 94%. He has diffuse wheezes on auscultation of his chest.

Dr. Juan Carlo

s Díaz T

His WBC count is 9800/mm (N 4,500 –11,000) with a slight left shift. His C-reactive protein level is mildly elevated and a chest radiograph reveals an interstitial infiltrate.

Which one of the following would be the most appropriate initial therapy?:

Dr. Juan Carlo

s Díaz T

a) A Beta-lactam antibiotic

b) A macrolide antibiotic

c) Amoxicillin

d) Ceftriaxone (Rocephin)

Dr. Juan Carlo

s Díaz T

Case # 163

A 75-year-old male is brought in by his family due to concerns about memory loss.

Which one of the following is best for determining whether or not he has dementia? :

Dr. Juan Carlo

s Díaz T

a) A Mini-Mental State Examination (MMSE)

b) Non–contrast-enhanced CT of the head

c) An electroencephalogram

d) A lumbar puncture

e) MRI of the head

Dr. Juan Carlo

s Díaz T

Case # 164

Of the following, which one has the greatest potential to spread via human-to-human transmission?:

Dr. Juan Carlo

s Díaz T

a) Pneumonic plague

b) Botulism

c) Typhoidal tularemia

d) Coxiella burnetii (Q fever)

e) Inhalation anthrax

Dr. Juan Carlo

s Díaz T

Case # 165

The mother of a 3-year-old male is concerned that he doesn’t like being held, doesn’t interact much with other children, and rarely smiles.

Of the following, which feature would be most helpful in distinguishing Asperger’s syndrome from autism in this patient?

Dr. Juan Carlo

s Díaz T

a) Repetitive fine motor mannerisms

b) Delayed gross motor development

c) Normal language development

d) Preoccupation with parts of objects

e) Focused patterns of intense interest

Dr. Juan Carlo

s Díaz T

Case # 166

A 76-year-old male is brought to your office by his son. The patient complains of dizziness that has slowly been worsening over the past year. His description is vague, but he says that he notices the dizziness when he tries to walk.

Dr. Juan Carlo

s Díaz T

The review of systems is normal, except for increasing problems with his “prostate” in the last 6 months, with dribbling and accidents at times.

His Mini-Mental State Examination (MMSE) score is 22 out of 30. No tremor is noted. A CBC, creatinine level, TSH level, vitamin B 12 level, and VDRL are all normal. Which one of the following should you do next?:

Dr. Juan Carlo

s Díaz T

a) Order a brainstem auditory evoked potential

b) Prescribe sertraline (Zoloft)

c) Order physical therapy

d) Order a brain MRI

e) Prescribe carbidopa/levodopa (Sinemet)

Dr. Juan Carlo

s Díaz T

Case # 167The most appropriate initial pharmacologic treatment of panic disorder is:

a) Valproic acid (Depakene)

b) Lithium

c) An SSRI

d) A tricyclic antidepressant

Dr. Juan Carlo

s Díaz T

Case # 168

A 24-year-old worker at a local day-care center has not had a menstrual period in over 2 months. A home pregnancy test is positive and is confirmed in your office. She is concerned because she was recently exposed to a child who was diagnosed with rubella. A serum rubella IgG antibody test is negative.

Dr. Juan Carlo

s Díaz T

Which one of the following would be the best course of action?

a) Order level III ultrasonography to screen for congenital anomalies

b) Repeat the serologic testing in 2–3 weeks

Dr. Juan Carlo

s Díaz T

c) Administer rubella immune globulin

d) Tell the patient she is immune to rubella and is not at risk

e) Administer live-virus rubella vaccine

Dr. Juan Carlo

s Díaz T

Case # 169

A 23-year-old male with Down syndrome is brought to your office by his parents. The patient has had a low-grade fever (approximately 100° F) for 7 days. The fever is not associated with rhinorrhea, sore throat, cough, dysuria, or shortness of breath. The parents note that their son has complained of aches in various places, and has not been eating well for several weeks.

Dr. Juan Carlo

s Díaz T

The physical examination is remarkable for swollen lymph glands in multiple places, pale conjunctivae, and an 8-lb weight loss since his last visit 1 month ago.

Which one of the following is most consistent with this patient’s symptoms?

Dr. Juan Carlo

s Díaz T

a) Urinary tract infection

b) Atypical pneumonia

c) Acute myeloid leukemia

d) Hodgkin’s lymphoma

e) Myocarditis

Dr. Juan Carlo

s Díaz T

Case # 170

Which one of the following is true regarding Osgood-Schlatter disease?

a) Complete symptom resolution usually occurs in 18–24 months

b) Effusions are often present on examination and knee range of motion is limited

Dr. Juan Carlo

s Díaz T

c) Most cases are triggered by a single traumatic event

d) Pain is localized to the inferior patellar pole at the origin of the patellar tendon

e) Pain usually begins at 20°– 30° of flexion

Dr. Juan Carlo

s Díaz T

Case # 171

You see a 9-month-old white male for a routine examination. He was seen at 2 months and 4 months for routine care and immunizations, but was not brought back at 6 months. The mother states that he has an excellent appetite. She expresses no concerns except that the baby "seems cranky”.

Dr. Juan Carlo

s Díaz T

The child is somewhat obese and pale, but the rest of the physical examination is unremarkable. A heel stick hematocrit done in your office is 26%

Known risk factors for iron deficiency at this age include:

Dr. Juan Carlo

s Díaz T

a) Maternal iron deficiency without anemia during pregnancy ( ) True ( ) False

b) Mild maternal anemia during pregnancy

( ) True ( ) False

c) Excessive blood loss during delivery( ) True ( ) False

Dr. Juan Carlo

s Díaz T

d) Prematurity ( ) True ( ) False

e) Breastfeeding ( ) True ( ) False

Dr. Juan Carlo

s Díaz T

Case # 172

You learn that the child drinks 1.5 quarts of whole cow's milk per day, with a daily dose of iron mixed into the milk. Therapeutic interventions could include

a) Dietary instruction regarding overfeeding

( ) True ( ) False

Dr. Juan Carlo

s Díaz T

b) Limiting cow's milk to 1 pint a day or less ( ) True ( ) False

c) Blood transfusion ( ) True ( ) False

d) Continuing oral iron therapy, and advising the mother to avoid mixing it in the milk ( ) True ( ) False

Dr. Juan Carlo

s Díaz T

e) Parenteral iron therapy ( ) True ( ) False

f) Oral vitamin C therapy ( ) True ( ) False

Dr. Juan Carlo

s Díaz T

Case # 173

A 42-year-old white male wants a dark mole removed from his thigh because he is afraid it is a melanoma.

a) A biopsy is indicated if the lesion has increased in size recently.

( ) True ( ) False

Dr. Juan Carlo

s Díaz T

b) Has an irregular, notched border ( ) True ( ) False

c) Is mixed reddish-blue in color ( ) True ( ) False

d) Is pruritic ( ) True ( ) False

Dr. Juan Carlo

s Díaz T

Case # 174

A biopsy confirms malignant melanoma in the superficial 0. 7 mm of the tissue submitted. Initial treatment should include:

a) Wide local excision ( ) True ( ) False

Dr. Juan Carlo

s Díaz T

b) 8,000 rad local radiation ( ) True ( ) False

c) Regional node dissection ( ) True ( ) False

d) Fluoxymesterone (Halotestin), 10 mg orally

( ) True ( ) False

Dr. Juan Carlo

s Díaz T

Case # 175

A 56-year-old white female complains of painful, burning dysesthesias in her hands and feet. Her past history is positive for cancer of the ovary treated with chemotherapy. Physical examination is normal except for evidence of a purely sensory peripheral neuropathy.

Dr. Juan Carlo

s Díaz T

The etiology of peripheral neuropathy includes

a) Toxic effects of antineoplastic medications ( ) True ( ) False

b) Paraneoplastic syndrome ( ) True ( ) False

Dr. Juan Carlo

s Díaz T

c) Vitamin B12 deficiency ( ) True ( ) False

d) Diabetes mellitus ( ) True ( ) False

e) Diabetes insipidus ( ) True ( ) False

Dr. Juan Carlo

s Díaz T

Treatment options include

a) Chelation therapy ( ) True ( ) False

b) Carbamazepine (Tegretol) ( ) True ( ) False

c) Tricyclic antidepressants such as amitriptyline (Elavil)( ) True ( ) False

Dr. Juan Carlo

s Díaz T

Case # 176

A 60-year-old white male has pain that starts in the hypogastric area that subsequently localizes in the left lower quadrant. His maximum temperature is 38.5 ° C ( 101.3 ° F) and he is able to take oral fluids without difficulty .He is mildly tender in the left lower quadrant on examination and has no rebound tenderness.

Dr. Juan Carlo

s Díaz T

Appropriate management at this time would include

a) Emergency surgical consultation( ) True ( ) False

b) CBC ( ) True ( ) False

c) Urinalysis ( ) True ( ) False

Dr. Juan Carlo

s Díaz T

d) Rectal examination ( ) True ( ) False

e) A liquid diet ( ) True ( ) False

f) Oral antibiotics ( ) True ( ) False

Dr. Juan Carlo

s Díaz T

In 10 days the patient is reevaluated. His abdominal pain has resolved and he is afebrile. Appropriate measures would now include

a) A low-residue diet ( ) True ( ) False

b) Colonoscopy( ) True ( ) False

Dr. Juan Carlo

s Díaz T

Case # 177

He follows your recommendations and does well until 2 years later when the symptoms recur. He has delayed seeing you because he thought the symptoms would go away. Examination shows him to be extremely uncomfortable, with a temperature of 38.8° C (102.0° F), and tenderness in the left lower quadrant.

Dr. Juan Carlo

s Díaz T

On palpation, you suspect there may be a left lower quadrant mass. His abdomen is moderately distended with decreased bowel sounds. Appropriate measures at this time would include

a) A barium enema ( ) True ( ) False

Dr. Juan Carlo

s Díaz T

b) A CT scan of the abdomen ( ) True ( ) False

c) A full liquid diet ( ) True ( ) False

d) Parenteral narcotics as needed ( ) True ( ) False

e) Broad-spectrum antibiotics ( ) True ( ) False

Dr. Juan Carlo

s Díaz T

Case # 178

You are covering the emergency department at your local community hospital. A 24-year-old previously healthy white female presents with complaints of dry mouth and blurred vision associated with nausea, malaise, and the recent onset of diplopia. You learn that 2 days ago she enjoyed home-canned foods at a friend's house.

Dr. Juan Carlo

s Díaz T

On examination you note a slight but definite ptosis and a slightly disconjugate gaze. Her examination is otherwise unremarkable and comprehensive blood chemistries are normal.

You decide which of the following tests might be diagnostic? :

Dr. Juan Carlo

s Díaz T

a) An MRI to rule out Guillain-Barre syndrome

( ) True ( ) False

b) A lumbar puncture to rule out a cerebrovascular accident ( ) True ( ) False

Dr. Juan Carlo

s Díaz T

c) A doxycyline challenge for tick paralysis ( ) True ( ) False

d) A psychiatric consultation for hysteria

( ) True ( ) False

Dr. Juan Carlo

s Díaz T

Results of appropriate testing are normal. The patient complains that she is getting weaker and notes a feeling of dyspnea. Appropriate actions at this time would include which of the following?:

a) Admit the patient to the intensive-care unit

( ) True ( ) False

Dr. Juan Carlo

s Díaz T

b) Obtain psychiatric consultation ( ) True ( ) False

c) Begin intravenous ciprofloxacin (Cipro) ( ) True ( ) False

d) Monitor respiratory status closely ( ) True ( ) False

Dr. Juan Carlo

s Díaz T

Case # 179

An obese 51-year-o1d white female consults you about her menstrual periods. For the past 6 months her menses have been irregular, spaced anywhere from 3-6 weeks apart. In addition, the flow has been considerably heavier and more prolonged than in the past. The only medication she is taking is a ginseng extract. She is not sexually active. Pelvic examination is normal.

Dr. Juan Carlo

s Díaz T

Appropriate diagnostic studies at this time include which of the following?

a) Thyroid-stimulating hormone (TSH) level( ) True ( ) False

b) CBC ( ) True ( ) False

Dr. Juan Carlo

s Díaz T

c) Papanicolaou (Pap) test ( ) True ( ) False

d) Office endometrial biopsy ( ) True ( ) False

Dr. Juan Carlo

s Díaz T

All laboratory tests ordered reveal normal results. The best approach to management at this time would include

a) Discontinuing ginseng ( ) True ( ) False

b) Dilatation and curettage ( ) True ( ) False

Dr. Juan Carlo

s Díaz T

c) Endometrial ablation ( ) True ( ) False

d) Medroxyprogesterone acetate (Provera), 5-10 mg daily 10 days of each month

( ) True ( ) False

Dr. Juan Carlo

s Díaz T

Within 8 months, she has no further bleeding but reports hot flushes. After discussion with the patient, appropriate therapeutic options include which of the following?: a) Prescribe conjugated estrogen supplementation

( ) True ( ) False

Dr. Juan Carlo

s Díaz T

b) Prescribe combined estrogen and progesterone therapy ( ) True ( ) False

c) Recommend dilatation and curettage

( ) True ( ) False

d) Begin therapy with danazol (Danocrine) ( ) True ( ) False

Dr. Juan Carlo

s Díaz T

Case # 180

An 84-year-old white male with a 5-year history of Alzheimer's disease is admitted to the nursing home because his family is having difficulty caring for him at home, due to increased confusion, incontinence, and combativeness. For the last week he has been having visual hallucinations.

Dr. Juan Carlo

s Díaz T

On admission to the nursing home he remains combative, striking out at staff and other residents, and is resistive to care. He is inattentive and distractible, and resists attempts at physical examination. His vital signs are stable, and a physical examination and laboratory workup fail to reveal any acute infections or other significant changes.

Dr. Juan Carlo

s Díaz T

Current medications likely contributing to his altered mental state include which of the following?

a) Lisinopril (Zestril) ( ) True ( ) False

b) Cimetidine (Tagamet) ( ) True ( ) False

Dr. Juan Carlo

s Díaz T

c) Nitroglycerin patch (Nitro-Dur) ( ) True ( ) False

d) Propoxyphene/acetaminophen (Darvocet-N 100)

( ) True ( ) False

Dr. Juan Carlo

s Díaz T

Which of the following historical features would suggest delirium, rather than progressive dementia, as a cause of his worsening condition?

a) Altered level of consciousness ( ) True ( ) False

b) Visual hallucinations for 1 week ( ) True ( ) False

Dr. Juan Carlo

s Díaz T

c) Short-term memory impairment ( ) True ( ) False

Dr. Juan Carlo

s Díaz T

He improves with behavioral management and medication changes, but remains combative and exhibits delusional and paranoid ideation. Which of the following neuroleptics could help control these problems with a relatively low risk of sedation and extrapyramidal side effects?

a) Olanzapine (Zyprexa) ( ) True ( ) False

Dr. Juan Carlo

s Díaz T

a) Risperidone (Risperdal)( ) True ( ) False

b) Haloperidol (Haldol) ( ) True ( ) False

c) Thioridazine (Mellaril) ( ) True ( ) False

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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