Case Studies Questions And Answers
ARDS m- mAnswer m- m53M, mfever, mcough, msore mthroat, mrunny mnose, mbody maches, mheadache,
mchills, mfatigue, mshortness mof mbreath, mand mprogressive mdifficulty mbreathing m,labored mbreathing
mwith maccessory mmuscles, mcrackled mlung msounds, mHR: m104, mBP: m78/48, mSaO2: m80% mon m100%
mnon-rebreather, mtemp: m37.9°C. mBecame mmore mlethargic, mproduced mincomprehensible mwords,
mand mwent minto man munresponsive mstate, m
Differential mlist:
Flu, mARDS
Diagnosis:
* mChest mX-Ray m- mbilateral minfiltrate
* mABG m- mrespiratory malkalosis m- mpH: m7.48, mPaCO2: m25mmHg, mPaO2: m78mmHg, mHCO3:
m28mEq/L
* mPAN mcultures: mSputum: m+ mfor mH1N1
* mEchocardiogram m- mnegative m(r/o mcongestive mheart mfailure)
* mBronchoscopy
* mCT mScan
* mCBC mand mCMP
Chronic mHepatitis mC m- mAnswer m- m35M, minebriated, mcomplaining mof mright mabdominal mpain,
mfatigue, mnausea mand mvomiting, mand mitching mof mthe mskin, mdrinking mup mto ma mbottle mof
mvodka mper mday. m
skin mand msclera mwere mmildly mjaundiced, mascites mwas mpresent, m102°F, m
hepatic mpanel, mELISA, mRIBA, mand mHCV mRNA, mand mcoagulation mpanel mwas mtaken. mThe mELISA,
mRIBA, mand mHCV mRNA mall mcame mback mto mbe mpositive mfor mhepatitis mC mantibodies. mAST/ALT
mratio- m2:1, mAST mand mALT mlevels mwere melevated; mprothrombin mtime mwas mprolonged;
mhyperbilirubinemia, mhypoalbuminemia, mand mhyperammonemia mwere mall mpresent. mCirrhosis
mcommon
HIV/AIDS m- mAnswer m- m57M, mpersistent/productive mcough, msore mthroat, moral mulcers, mweakness,
mfever mand mreport mof mconsistent mweight mloss. mhospitalized mafter ma mcar mcrash min m1982
,mreceived m2 munits mof mPRBCs mand mhas mnever mvisited ma mdentist. mpale, mdiaphoretic mand
memaciated.
Differential mDiagnoses:
mInfection m(systemic, mrespiratory, mor mGI)
mTuberculosis
mCancer
mHIV minfection
Diagnosis: m6 mepisodes mof msuspected mundiagnosed mpneumonia msince m1983 mand mhas mbeen
m"sick mfor mas mlong mas mhe mcan mremember." mswollen mlymph mnodes, mbilateral mweakness mof mall
mextremities, msevere mcachexia, mand msmall mround, mbluish-red mlumps mthe msize mof mpeas mall
mover mthe minner mand manterior mthighs. mpositive mfor mHIV, mand mhis mCD4 mcount mis m7 mcells mper
mmicroliter, mwell mbelow mthe mcut-off mfor mAIDS m(200 mcells mper mmicroliter). mThe mlumps mon mhis
mthighs mare mdetermined mto mbe mKaposi's msarcoma, ma mcancerous mtumor mof mthe mconnective
mtissue mcommonly maffecting mpersons mwith mweakened mimmune msystems. mA msputum mculture
mreveals mTB mand ma mchest mX-ray mshows mextensive mdamage mto mthe mlung mtissue, mover m75%.
HIV m- mAnswer m- mPatient mPresentation
23M: mdiarrhea m(>12 mBM's mper mday), mvomiting mand manorexia. mVS: mT m99.8, mHR m110, mRR m16,
mPOx m98% mon mRA. mCBC, mBMP, mand mstool mcultures. melevated mcreatinine m2.8, mNa+ m156, mand
mdecreased mK+ m3.1, m. m
Diagnosis: mAdmitted m4 mdehydration mwith mmild mrenal mfailure. mHis mstool mculture: mpositive mfor
mShigella mand mhe mwas mstarted mon mCipro®. mdiagnosed ma myear mago mafter mtesting mpositive mfor
msyphilis, mCD4 mof m202 m(17%) mand mViral mLoad m(VL) mof m5637
Meningitis m- mAnswer m- m34M mfevers, mhead mache, ma mstiff mneck, mand mphotosensitivity.
blood mcultures, murine mculture, msputum mculture, mand ma mspinal mtap mwas mperformed. mDiagnosis:
mstarted mon mIV mceftriaxone mand mvancomycin.
Mononucleosis m- mAnswer m- m9M mfever, mchills, mgeneralized mmalaise, mfatigue mand msore mthroat
mfor mthe mpast m7 mdays. mPt mstates mthat mhe mis munable mto meat m+ mpain mw/swallowing mrelated
mto msore mthroat. munable mto mwalk mfar mwithout mfeeling mlike mhe mis mgoing mto mcollapse. mPt
mdenies mcough. m+4 mB/L mswollen mcervical mlymph mnodes. mTonsils m+4 mB/L mwith mexudate. mPt
mhad mpositive mpharyngitis. mPt's mskin mis mpale mand mdiaphoretic. mpositive mupper mleft-sided
mquadrant mabdominal mtenderness. mHR: m103 mbpm, mBP: m126/80, mT: m102.0 mF, mPOx: m98%, mRR:
m28. m
,Differential mList:
Streptococcal minfection, mLyme mdisease, mmononucleosis
Diagnosis:
mRapid mMono mTest: mPositive. mRapid mStrep mA mTest: mPositive. mCMP mand mCBC mw/differential
mwere mordered. mWBC melevated. mCMP mwas mWNL. mLiver mfunction mwas mWNL. mDiagnosis:
mMononucleosis mand msecondary minfection mof mStreptococcal mA. mStreptococcal mA mbacterial
minfection mis mfrequently mconcurrent mwith mMononucleosis mviral minfection.
m- mAnswer m- mA m6 mmonth mold mfemale, mE.C., mpresents mto mthe mER mwith mher mparents min
mJanuary mwith mrhinorrhea, mcough, mwheezing mand ma mlow-grade mfever mof m37.5 mdegrees
mCelsius. mUpon minitial massessment, mthe mRN mnotices mE.C. mto mhave ma mslight mincreased mwork
mof mbreathing, mmild mfussiness mand mpallor. mE.C.'s mparents mcomplain mof mher mhaving mupper
mrespiratory mtract msymptoms mand mdecreased moral mintake mover mthe mlast m2-3 mdays. mE.C.'s
mhistory mis mpositive mfor mprematurity mof m35 mweeks. mAs mE.C.'s mstay min mthe mER mcontinues,
mher mrespiratory mstatus mstarts mto mdeteriorate. mShe mbecomes mtachypneic m(RR mof m70 mbreaths
mper mminute) mand mher mSaO2 mdrops mto m90% mon mroom mair. mIn mthe mER, mthey mput mE.C. mon
m2 mliters mof moxygen mvia ma mnasal mcannula, mplace man mIV, mstart mfluids, mand mtransfer mher mto
mthe mPICU. mE.C. mpresents mto mthe mPICU mwith mmild mto msevere mretractions, mwheezing, mand
mcyanosis. mHer mtemperature mhas mincreased mto m38.5 mdegrees mCelsius, mshe mis mtachycardic, mher
mBP mis mstable, mher mSaO2 mhas mdropped mto mthe mmid m80s meven mwith msupplemental mO2, mand
mher mcapillary mrefill mis m>2seconds. mShe mis mstarted mon mIV mfluids mof mD5 m0.45 mNaCl mbut mE.C.
mdoes mnot mtolerate mother mforms mof moxygen madministration msuch mas ma mface mmask mand mthe
mdecision mis mmade mto mintubate mthe mchild mto mprevent mrespiratory marrest. mAfter ma msuccessful
mintubation, mlabs mare mdrawn, mCXR mis mcompleted mand mcultures mare mcollected. m(Many mtimes
mwe mdo mnot mcollect mlabs mprior mto mintubating ma mchild mif mwe mdo mnot mhave mproper maccess
mfor mfear mof magitating mthe mpatient mmore mand mcausing ma mmore mrapid mdeterioration min
mrespiratory mstatus).
Differential mDiagnoses
Acute masthma mattack
Bronchiolitis
Croup
Influenza
Tests m& mDiagnosis
, Chest mx-ray mshows mmild matelectasis min mbilateral mlower mlobes
ABG mindicates mprimary mrespiratory malkalosis: mpH mof m7.5, mPaCO2 mof m30, mand mHCO3- m24
CBC mresults mshow man mincrease min mWBC
CMP mis mrelatively mnormal
Blood mcultures mand murinalysis mar
Acinetobacter mPneumonia m- mAnswer m- mPatient mPresentation:
A.G. m, ma m40 myear mold mAfghan mNational mArmy mmale ms/p mIED m(improvised mexplosive mdevice)
mblast mto mface, mchest mand mlimbs, mwas mbeing mtreated min ma mcombat mICU mfor mdevastating
mfacial mand mextremity minjuries. mPt mhas mbeen mmechanically mventilated mvia mtracheostomy msince
mhis madmission mdue mto mthe mextent mof mhis mface mwounds. mA.G. mis mbecoming mincreasingly
mfebrile, mdifficult mto mwean mfrom mthe mventilator mand mhas mworsening mx-ray mimaging mstudies. m
VITAL mSIGNS: mHeart mRate: m110, mBlood mPressure: m92/64, mSpO2: m88, mAxillary mTemperature:
m39.0
CBC: mWBC: m22, mRBC: m5, mHCT: m8, mHGB:26, mPLT: m200
ABG: mpH: m7.19, mPaCO2: m65, mPaO2: m55, mHCO3: m28
DIFFERENTIAL mDIAGNOSES:
Klebsiella mpneumonia, mMRSA mpneumonia, m
DIAGNOSIS:
Chest mx-ray mwas mperformed mand mrevealed mlarge mareas mof mconsolidation min mboth mlungs
mindicative mof mpneumonia. mA.G. munderwent mmultiple mbedside mbronchoscopies mto mtake
msputum msamples mand mto mwash mout mthe mcopious mamounts mof msecretions mthat mhe mcould
mnot mclear mon mhis mown. mA mbronchoscopy mis ma mprocedure min mwhich mthe mdoctor muses man
mendoscope mto mlook mat mthe mpatient's mairway, mstarting mwith mthe mmouth mand mdown mto mthe
mlower mlobes mof meach mlung. mThe msputum mresults mcame mback mpositive mfor mmulti-drug
mresistant mXXXX mXXXis ma mbacterium mcommon mto msoil maround mthe mworld, mwhich min mthe mpast
mhas mnot mbeen ma mworrisome mpathogen. mHowever, min mrecent myears, mthis mbacterium mhas
mbeen mcausing mproblems min mthe mwar mwounded mand mparticularly mthose mwith mIED mblast
minjuries mdue mto mthe mamount mof msoil mand mdirt mbecoming mengrained min mthe mwounds.
Bacterial mvaginosis/vaginitis m- mAnswer m- matient mPresentation
ARDS m- mAnswer m- m53M, mfever, mcough, msore mthroat, mrunny mnose, mbody maches, mheadache,
mchills, mfatigue, mshortness mof mbreath, mand mprogressive mdifficulty mbreathing m,labored mbreathing
mwith maccessory mmuscles, mcrackled mlung msounds, mHR: m104, mBP: m78/48, mSaO2: m80% mon m100%
mnon-rebreather, mtemp: m37.9°C. mBecame mmore mlethargic, mproduced mincomprehensible mwords,
mand mwent minto man munresponsive mstate, m
Differential mlist:
Flu, mARDS
Diagnosis:
* mChest mX-Ray m- mbilateral minfiltrate
* mABG m- mrespiratory malkalosis m- mpH: m7.48, mPaCO2: m25mmHg, mPaO2: m78mmHg, mHCO3:
m28mEq/L
* mPAN mcultures: mSputum: m+ mfor mH1N1
* mEchocardiogram m- mnegative m(r/o mcongestive mheart mfailure)
* mBronchoscopy
* mCT mScan
* mCBC mand mCMP
Chronic mHepatitis mC m- mAnswer m- m35M, minebriated, mcomplaining mof mright mabdominal mpain,
mfatigue, mnausea mand mvomiting, mand mitching mof mthe mskin, mdrinking mup mto ma mbottle mof
mvodka mper mday. m
skin mand msclera mwere mmildly mjaundiced, mascites mwas mpresent, m102°F, m
hepatic mpanel, mELISA, mRIBA, mand mHCV mRNA, mand mcoagulation mpanel mwas mtaken. mThe mELISA,
mRIBA, mand mHCV mRNA mall mcame mback mto mbe mpositive mfor mhepatitis mC mantibodies. mAST/ALT
mratio- m2:1, mAST mand mALT mlevels mwere melevated; mprothrombin mtime mwas mprolonged;
mhyperbilirubinemia, mhypoalbuminemia, mand mhyperammonemia mwere mall mpresent. mCirrhosis
mcommon
HIV/AIDS m- mAnswer m- m57M, mpersistent/productive mcough, msore mthroat, moral mulcers, mweakness,
mfever mand mreport mof mconsistent mweight mloss. mhospitalized mafter ma mcar mcrash min m1982
,mreceived m2 munits mof mPRBCs mand mhas mnever mvisited ma mdentist. mpale, mdiaphoretic mand
memaciated.
Differential mDiagnoses:
mInfection m(systemic, mrespiratory, mor mGI)
mTuberculosis
mCancer
mHIV minfection
Diagnosis: m6 mepisodes mof msuspected mundiagnosed mpneumonia msince m1983 mand mhas mbeen
m"sick mfor mas mlong mas mhe mcan mremember." mswollen mlymph mnodes, mbilateral mweakness mof mall
mextremities, msevere mcachexia, mand msmall mround, mbluish-red mlumps mthe msize mof mpeas mall
mover mthe minner mand manterior mthighs. mpositive mfor mHIV, mand mhis mCD4 mcount mis m7 mcells mper
mmicroliter, mwell mbelow mthe mcut-off mfor mAIDS m(200 mcells mper mmicroliter). mThe mlumps mon mhis
mthighs mare mdetermined mto mbe mKaposi's msarcoma, ma mcancerous mtumor mof mthe mconnective
mtissue mcommonly maffecting mpersons mwith mweakened mimmune msystems. mA msputum mculture
mreveals mTB mand ma mchest mX-ray mshows mextensive mdamage mto mthe mlung mtissue, mover m75%.
HIV m- mAnswer m- mPatient mPresentation
23M: mdiarrhea m(>12 mBM's mper mday), mvomiting mand manorexia. mVS: mT m99.8, mHR m110, mRR m16,
mPOx m98% mon mRA. mCBC, mBMP, mand mstool mcultures. melevated mcreatinine m2.8, mNa+ m156, mand
mdecreased mK+ m3.1, m. m
Diagnosis: mAdmitted m4 mdehydration mwith mmild mrenal mfailure. mHis mstool mculture: mpositive mfor
mShigella mand mhe mwas mstarted mon mCipro®. mdiagnosed ma myear mago mafter mtesting mpositive mfor
msyphilis, mCD4 mof m202 m(17%) mand mViral mLoad m(VL) mof m5637
Meningitis m- mAnswer m- m34M mfevers, mhead mache, ma mstiff mneck, mand mphotosensitivity.
blood mcultures, murine mculture, msputum mculture, mand ma mspinal mtap mwas mperformed. mDiagnosis:
mstarted mon mIV mceftriaxone mand mvancomycin.
Mononucleosis m- mAnswer m- m9M mfever, mchills, mgeneralized mmalaise, mfatigue mand msore mthroat
mfor mthe mpast m7 mdays. mPt mstates mthat mhe mis munable mto meat m+ mpain mw/swallowing mrelated
mto msore mthroat. munable mto mwalk mfar mwithout mfeeling mlike mhe mis mgoing mto mcollapse. mPt
mdenies mcough. m+4 mB/L mswollen mcervical mlymph mnodes. mTonsils m+4 mB/L mwith mexudate. mPt
mhad mpositive mpharyngitis. mPt's mskin mis mpale mand mdiaphoretic. mpositive mupper mleft-sided
mquadrant mabdominal mtenderness. mHR: m103 mbpm, mBP: m126/80, mT: m102.0 mF, mPOx: m98%, mRR:
m28. m
,Differential mList:
Streptococcal minfection, mLyme mdisease, mmononucleosis
Diagnosis:
mRapid mMono mTest: mPositive. mRapid mStrep mA mTest: mPositive. mCMP mand mCBC mw/differential
mwere mordered. mWBC melevated. mCMP mwas mWNL. mLiver mfunction mwas mWNL. mDiagnosis:
mMononucleosis mand msecondary minfection mof mStreptococcal mA. mStreptococcal mA mbacterial
minfection mis mfrequently mconcurrent mwith mMononucleosis mviral minfection.
m- mAnswer m- mA m6 mmonth mold mfemale, mE.C., mpresents mto mthe mER mwith mher mparents min
mJanuary mwith mrhinorrhea, mcough, mwheezing mand ma mlow-grade mfever mof m37.5 mdegrees
mCelsius. mUpon minitial massessment, mthe mRN mnotices mE.C. mto mhave ma mslight mincreased mwork
mof mbreathing, mmild mfussiness mand mpallor. mE.C.'s mparents mcomplain mof mher mhaving mupper
mrespiratory mtract msymptoms mand mdecreased moral mintake mover mthe mlast m2-3 mdays. mE.C.'s
mhistory mis mpositive mfor mprematurity mof m35 mweeks. mAs mE.C.'s mstay min mthe mER mcontinues,
mher mrespiratory mstatus mstarts mto mdeteriorate. mShe mbecomes mtachypneic m(RR mof m70 mbreaths
mper mminute) mand mher mSaO2 mdrops mto m90% mon mroom mair. mIn mthe mER, mthey mput mE.C. mon
m2 mliters mof moxygen mvia ma mnasal mcannula, mplace man mIV, mstart mfluids, mand mtransfer mher mto
mthe mPICU. mE.C. mpresents mto mthe mPICU mwith mmild mto msevere mretractions, mwheezing, mand
mcyanosis. mHer mtemperature mhas mincreased mto m38.5 mdegrees mCelsius, mshe mis mtachycardic, mher
mBP mis mstable, mher mSaO2 mhas mdropped mto mthe mmid m80s meven mwith msupplemental mO2, mand
mher mcapillary mrefill mis m>2seconds. mShe mis mstarted mon mIV mfluids mof mD5 m0.45 mNaCl mbut mE.C.
mdoes mnot mtolerate mother mforms mof moxygen madministration msuch mas ma mface mmask mand mthe
mdecision mis mmade mto mintubate mthe mchild mto mprevent mrespiratory marrest. mAfter ma msuccessful
mintubation, mlabs mare mdrawn, mCXR mis mcompleted mand mcultures mare mcollected. m(Many mtimes
mwe mdo mnot mcollect mlabs mprior mto mintubating ma mchild mif mwe mdo mnot mhave mproper maccess
mfor mfear mof magitating mthe mpatient mmore mand mcausing ma mmore mrapid mdeterioration min
mrespiratory mstatus).
Differential mDiagnoses
Acute masthma mattack
Bronchiolitis
Croup
Influenza
Tests m& mDiagnosis
, Chest mx-ray mshows mmild matelectasis min mbilateral mlower mlobes
ABG mindicates mprimary mrespiratory malkalosis: mpH mof m7.5, mPaCO2 mof m30, mand mHCO3- m24
CBC mresults mshow man mincrease min mWBC
CMP mis mrelatively mnormal
Blood mcultures mand murinalysis mar
Acinetobacter mPneumonia m- mAnswer m- mPatient mPresentation:
A.G. m, ma m40 myear mold mAfghan mNational mArmy mmale ms/p mIED m(improvised mexplosive mdevice)
mblast mto mface, mchest mand mlimbs, mwas mbeing mtreated min ma mcombat mICU mfor mdevastating
mfacial mand mextremity minjuries. mPt mhas mbeen mmechanically mventilated mvia mtracheostomy msince
mhis madmission mdue mto mthe mextent mof mhis mface mwounds. mA.G. mis mbecoming mincreasingly
mfebrile, mdifficult mto mwean mfrom mthe mventilator mand mhas mworsening mx-ray mimaging mstudies. m
VITAL mSIGNS: mHeart mRate: m110, mBlood mPressure: m92/64, mSpO2: m88, mAxillary mTemperature:
m39.0
CBC: mWBC: m22, mRBC: m5, mHCT: m8, mHGB:26, mPLT: m200
ABG: mpH: m7.19, mPaCO2: m65, mPaO2: m55, mHCO3: m28
DIFFERENTIAL mDIAGNOSES:
Klebsiella mpneumonia, mMRSA mpneumonia, m
DIAGNOSIS:
Chest mx-ray mwas mperformed mand mrevealed mlarge mareas mof mconsolidation min mboth mlungs
mindicative mof mpneumonia. mA.G. munderwent mmultiple mbedside mbronchoscopies mto mtake
msputum msamples mand mto mwash mout mthe mcopious mamounts mof msecretions mthat mhe mcould
mnot mclear mon mhis mown. mA mbronchoscopy mis ma mprocedure min mwhich mthe mdoctor muses man
mendoscope mto mlook mat mthe mpatient's mairway, mstarting mwith mthe mmouth mand mdown mto mthe
mlower mlobes mof meach mlung. mThe msputum mresults mcame mback mpositive mfor mmulti-drug
mresistant mXXXX mXXXis ma mbacterium mcommon mto msoil maround mthe mworld, mwhich min mthe mpast
mhas mnot mbeen ma mworrisome mpathogen. mHowever, min mrecent myears, mthis mbacterium mhas
mbeen mcausing mproblems min mthe mwar mwounded mand mparticularly mthose mwith mIED mblast
minjuries mdue mto mthe mamount mof msoil mand mdirt mbecoming mengrained min mthe mwounds.
Bacterial mvaginosis/vaginitis m- mAnswer m- matient mPresentation
