Patient 1: Questions (you may use the back of the paper if needed): I. Write a problem list for this patient using outline form. List the most important problem as Number 1. Please organize the outline so that related problems are placed together. II. Write the differential diagnosis for the chief problem. Please list the most likely causes first. Be as complete as possible. III. Write a plan for diagnostic tests for this patient. Please list in order that you would prefer, add a short phrase describing why an individual procedure or test battery is necessary. IV. After the patient is sent home he returns 2 weeks later with the chief complaint of marked mental confusion without focal neurologic changes. List 4 potential causes of this change in mental status.

 

1.

I. Cirrhosis

    1. Hepatic Encephalopathy
      1. Tremor, asterixes
      2. Irritability, stupor

B. Chronic liver disease

    1. fetor hepaticus
    2. jaundice
    3. spider telangiectasias
    4. hypogonadism
    5. elevated LFTs
    6. peripheral edema

      7.  

      1. Portal Hypertension
        1. Ascites

          2. B. ? Varices, bleeding

        2. Splenomegaly
          1. thrombocytopenia
          2. anemia
      2. Systolic ejection murmur

IV. Status/post flu like illness

Differential Diagnosis of Cirrhosis

Alcoholic, post-necrotic; cardiac, primary biliary, Infiltrative disease (hemochromatosis, amyloid, Wilson’s, alpha-one anti-trypsinase deficiency, TB), autoimmune hepatitis, fatty liver, hepatic vein thrombosis, tumor(hepatoma, mets) , lymphoma, extramedullary hematopoiesis

Initial workup: LFTS, ammonia, PT, PTT, look at peripheral blood film, hepatitis serology (ABC) Fe TIBC, Ferritin, ceruloplasmin, Alpha1 anti-trypsinase level, ANA, SPEP, PPD, blood cultures

Paracentesis, US or ct of abdomen if cardiac cirrhosis then echocardiogram

Lastly, liver biopsy

 

 

Conditions which may precipitate hepatic encephalopathy: GI bleeding, increased protein intake, benzodiazepams/narcotics, alkalosis, hypovolemia, infection, hypokalemia, azotemia, constipation, diuretics, infection/surgery, super imposed acute liver disease, progressive liver disease

Patient 2:

  1. As in Patient 1, write an organized complete problem list.
  2. What is the differential diagnosis of the chest pain? Please begin with the most likely cause(s).
  3. Four days later he was much improved. Suddenly, he became severely dyspneic, he could not lie flat, the BP fell to 90/65, the pulse rose to 120, and moist bibasilar rales to the mid-scapula could be heard. His neck veins were distended and a new loud grade 4/6 pansystolic murmur was heard at the lower left sternal border. It radiated to the apex and base of the heart. No thrill was palpable. What are the possible causes of this sudden decompensation?

 

 

I. Unstable Angina, Possible MI

A. history of stable angina for one year

B. Increasing frequency of exertional angina

C. Acute pain, nausea, diaphoresis

D. + family history for CAD, HTN, DM

II. Hypertension

A. Poor control X 10 years

B. S4 gallop

III. DM for 3 years

Diet tx alone

 

Differential DX of chest pain:

MI/angina, unstable angina, Prinzmetal’s, or angina associated with AS

Pericarditis, myocarditis

Thoracic aneurysm (dissection)

Pulmonary emboli, primary pulmonary hypertension, pneumonia, pleurisy, pneumothorax, tracheobronchitis, mediastinitis,

Esophageal spasm, reflux

Musculoskeletal (Tsetse’s syndrome)

Chest pain may precede appearance of vesicles in herpes Zoster

 

Sudden decompensation:

Papillary muscle necrosis with MR

VSD

Ventricular aneurysm with rupture

Patient 3, Questions:

What causes of GI bleeding in this elderly woman need to be considered now? Write a list and suggest a diagnosis that might have been missed in the earlier work up.

 

Upper GI

PUD

Gastritis

Varices

Mallory-Weis tear

Gastric CA

Hemobilia

Rupture of aortic aneurysm into small intestine

Lower GI Bleeding

AVM

Tumor

Polyps

Chronic hemorrhoids

Diverticulum

UC/RE

Thrombocytopenia

Hemophilia

Platelet dysfunction

Uremia

Vasculitis

Meckel’s

Fistulae

Fissures

Foreign bodies

Salmonella, other enterobacteria infections

 

Angiography, repeat endoscopy

Patient 4.

a. What substance ingestion appears likely on the basis of the patient's presentation? ASA

b. How would you describe his acid base status?

Metabolic acidosis and respiratory alkalosis

Patient 5.

a. What condition underlies the patient's confusion? sepsis

b. How would you describe his acid base status? Metabolic acidosis with respiratory alkalosis

Patient 6.

a. What condition is suggested by the clinical presentation and laboratory findings?

rhabdomyolysis

 

Patient 7.

a. What disorder is most likely to be present? Hypothyroidism

b. What tests should be ordered? TSH first, then possibly T4, T3, cortisol

Patient 8.

a. What is the most likely cause of his abdominal pain? Pancreatitis

b. What additional work up should be obtained?

Amylase, lipase; US of the abdomen with reference to gall bladder, biliary tree and pancreas, chest x-ray to look for free air under the diaphragm, rarely, EKG (inferior wall MI will present as abdominal pain)

Patient 9.

a. What is the most likely cause of her chest abnormality and skin disorder? Sarcoidosis

b. On her next visit, a scalene lymph node is palpated. Biopsy of this node will disclose what finding? Non-caseating granuloma

Patient 10.

a. What will his urine sodium excretion be? Low

b. Which will be greater? His sodium deficit or his water deficit? His water deficit

Patient 11.

For each of the conditions listed name the most likely associated cause of hypertension:

a. Hypokalemia before initiation of diuretic therapy. Conn’s (hyperaldosteronism) Cushing’s

b. Palpitations, weight loss, hyperglycemia. Pheochromocytoma

c. Abdominal bruit. Renovascular HTN

d. Bilateral enlarged, palpable kidneys in a person with a history of familial renal

failure. PCKD

Patient 12.

a. What is the most likely cause of her prolonged PT and PTT? Vitamin K deficiency

b. What pro-coagulation factors are most likely to be diminished? II, IV, IX, X

c. What inhibitors of clotting are likely to be diminished?

Protein C and S

 

Patient 13.

a. What two inflammatory bowel disorders must be considered? Crohn’s, UC

b. What infectious disorders must be considered?

Salmonella, amoebiasis, shigella, Yersinia, Campylobacter, TB, pseudomembranous colitis

Patient 14.

a. What is the acid base abnormality? Metabolic acidosis

b. Calculate the anion gap: 140-(102+4) =34

c. The formula for the calculation of the serum osmolality is: OSM = (Na) X 2 + (glucose)/18 + BUN/2.8

Based on this formula what is the osmolar gap in this patient? 375- (280 +5 + 5) or

375-290 = 85 (pretty darn high!)

d. What is the most likely cause of the acid base abnormality in this patient. Methanol or ethylene glycol poisoning

Patient 15.

a. What does the fundus show? Papilledema

b. Although it is clear that she has hypertension, can you give her a more precise diagnosis? Malignant hypertension

c. What is the cause of the exacerbation of her hypertension?

Abrupt discontinuation of clonidine—clonidine rebound hypertension

Patient 16.

a. What is the most likely cause of her arthritis? RA

b. What laboratory test will be most helpful? RF

c. What is the cause of her right hand numbness? Ulnar nerve palsy (mononeuritis with vasculitis—rare possibility)

d. What additional physical finding might be observed near the patients elbows? Rheumatoid nodules

Patient 17.

a. What is the most likely valvular disorder present? AI

b. Name 3 diseases associated with this valvular dysfunction. Mark the disease

that is associated with the hand findings demonstrated in the photograph.

*Marfan’s syndrome, syphilitic aortitis, rheumatic fever, bicuspid aortic valve, ankylosing spondylitis , congenital fenestrations, dissecting aorta, hypertension, VSD with prolapse

 

Patient 18.

a. What is the rhythm disturbance shown on the EKG (ECG)? Atrial Fibrillation

b. Name three conditions associated with this disorder:

coronary artery disease, cardiomyopathy, pulmonary embolism, MS, hyperthyroidism, pericarditis, myocarditis, alcohol (holiday heart), WPW, and quite a few others.

Patient 19.

a. What are the main abnormalities in his EKG? ST wave elevation and acute T in II, III, AVF with reciprocal changes in lateral leads

b. What is the cause of his EKG changes?

Inferior lateral ischemia, MI

Patient 20.

a. What is the most likely cause of her anemia? Pernicious anemia B12 deficiency

b. Should she receive a blood transfusion while awaiting diagnostic tests? Why or

why not? No, she is stable and will respond to B12

Patient 21.

a. What is the most likely cause of the anemia? Iron deficiency

b. What tests need to be ordered to evaluate the anemia? TSI, TIBC, Ferritin (also GI studies are appropriate (Upper and lower endoscopy)

c. Name two other disorders that need to be considered. Thalassemia minor, anemia of chronic disease, sideroblastic anemia

Patient 22.

a. What is the cause of this woman's fever? Pneumonia

b. Name three underlying conditions which predispose to the condition named in part

a?

alcoholism, immune suppression, aspiration, DM

Patient 23.

a. What is the most likely cause of her chest pain? Pericarditis

b. what additional imaging technique is required? echocardiogram

c. What is the underlying disorder? SLE

d. Name two additional physical findings which should be looked for in this patient. Kusmaul’s sign, pulsus paradoxus, friction rub, narrow pulse pressure, Ewart’s sign

Patient 24.

a. What are the main abnormalities shown? Vascular congestion, Kerley B lines, cardiomegaly, cephalizaton of flow

b. What is the cause of her dyspnea? CHF with Pulmonary edema