This document contains a series of clinical case studies presented by Dr. Juan Carlos Díaz Torre. Each case presents a patient scenario, possible diagnoses or treatment options, and questions for the reader to answer. The cases cover topics like depression, frostbite treatment, preterm labor prevention, and corneal abrasion management. The document is intended as a teaching tool using brief real-world medical scenarios.

1. CURSO DE INGLÉS
ENGLISH COURSE
Dr. Juan Carlos Díaz Torre
Pediatra Neonatólogo
dr_diaz_torre@hotmail.com
(779) 100 - 40 - 26
DR.JCDT
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2. BRIEF CLINICAL CASES
CASOS CLÍNICOS BREVES
(14)
Dr. Juan Carlos Díaz Torre
Pediatra Neonatólogo
dr_diaz_torre@hotmail.com
(779) 100 - 40 - 26
DR.JCDT
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Case # 181
A 58-year-old male with a long history
of hypertension and coronary artery
disease comes to see you 3 weeks
after an acute myocardial infarction. His
hospitalization was punctuated by
intermittent episodes of symptomatic
cardiac arrhythmias and difficulties in
controlling his blood pressure.

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Other than a history of a seizure disorder
controlled by phenytoin (Dilantin), his
past medical history is unremarkable. He
complains of fatigue, headache, and lack
of energy. After determining that his
symptoms are not the result of
medications or other systemic problems,
you conclude that he is depressed and
would benefit from an antidepressant.
Appropriate medications include which of
the following?:

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a) Nortriptyline (Pamelor)
( ) True ( ) False
b) Paroxetine (Paxil)
( ) True ( ) False
c) Bupropion (Wellbutrin)
( ) True ( ) False
d) Venlafaxine (Effexor)
( ) True ( ) False

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In order to maximize compliance, you tell
him which of the following?
a) Side effects, such as nausea and
sedation, are often transient and
disappear after 1-2 weeks
( ) True ( ) False

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b) It may take several weeks for
improvement to be noted, and up
to 8 weeks for a full therapeutic
response
( ) True ( ) False
c) Antidepressants are most effective
when taken continuously
( ) True ( ) False

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d) Antidepressants usually can be
discontinued 3-4 months after the
initial episode
( ) True ( )False

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Four weeks later, the patient returns to
your office. His depression is somewhat
better, but he is complaining of erectile
dysfunction and persistent daytime
sleepiness.
Which of the following would be
appropriate alternative drugs?
a) Nefazadone (Serzone)
( ) True ( )False

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b) Methylphenidate (Ritalin)
( ) True ( ) False
c) Sertraline (Zoloft)
( ) True ( )False
d) Trazodone (Desyrel)
( ) True ( ) False

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Case # 182
A 15-month-old African-American male
is brought to your office by his mother,
who gives a history of a cold that started
about 10 days ago. Initially, he had a
low-grade fever, a runny nose, and a
slight cough. Now the fever has returned
and he has become fussy. The nurse
records a temperature of 39.0° C
(102.2° F).

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You examine him and find a
bulging, immobile tympanic membrane.
Otherwise, he has normal physical
findings. You review your records and
note that he had an episode of acute
otitis media only 6 months ago. It had
resolved at a subsequent follow-up visit
after treatment with amoxicillin.
You make a presumptive diagnosis of a
second episode of acute otitis media. You
would now advise which of the
following?:

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a) Myringotomy and culture
( ) True ( ) False
b) Antibiotic therapy
( ) True ( ) False
c) Referral for pressure equalization
tube placement
( ) True ( ) False

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d) Referral for adenoidectomy
( ) True ( ) False
e) Total and differential WBC count
( ) True ( )False

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Two weeks later the child is brought
back to the office, and you note that the
tympanic membranes are retracted and
immobile. He is now afebrile and
asymptomatic.
You make a diagnosis of persistent
middle ear effusion and advise the
mother that there is persistent fluid
behind the eardrum. Since this is his
second episode of otitis, the next phase
of treatment will require:

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a) Myringotomy and culture
( ) True ( ) False
b) Referral for pressure equalization
tube placement
( ) True ( ) False
c) Referral for adenoidectomy
( ) True ( ) False

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d) Periodic observation until resolved
( ) True ( ) False

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Case # 183
You have a patient who is going skiing for
the first time. He comes to you for advice
concerning the prevention of injuries and
frostbite . After discussing
musculoskeletal injuries, you would say
that frostbite:

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a) Is more profound when it occurs at
high altitude than when it occurs at
sea level, if all other factors are
equal.
( ) True ( ) False
b) Can occur when the wind chill factor
is below freezing even though the
ambient temperature is above
freezing.
( )True ( ) False

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c) Is less likely to occur if, just prior to
skiing, a small amount of alcohol is
ingested for its vasodilating effect.
( ) True ( ) False
d) Can be self -treated if radiant heat is
readily available.
( ) True ( ) False

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In spite of your good advice, the patient
sustains a cold injury to the feet. He is
taken to the clinic at the base of the
mountain where the Doctor on duty
observes the toes on both feet to be firm
and cold to touch, with a pale, gray,
bloodless appearance.
Appropriate treatment options would
include:

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a) Wrapping the patient in a warm
blanket.
( ) True ( ) False
b) Giving an alcoholic beverage as soon
as practical.
( ) True ( )False

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c) Massaging the toes for a few minutes
prior to instituting any other local
therapy.
( ) True ( ) False
d) Rapidly rewarming the feet in
circulating water at 90.0 -108.0° F.
( ) True ( )False

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e) Having the patient walk around as
soon as rewarming is complete.
( ) True ( ) False
f) Telling the patient to apply pressure
dressings at night prior to retiring.
( ) True ( ) False
g) Surgically removing any part of the
toes which is likely to become
devitalized.
( ) True ( ) False

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Case # 184
A 24-year-old white female comes in for
prenatal care for her third pregnancy.
Both of her previous pregnancies
resulted in preterm births at 30 weeks
gestation. Her medical and obstetric
history are otherwise negative .

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Which of the following measures has
been demonstrated by randomized trial
to reduce the likelihood of premature
birth in this situation?:
a) Ritodrine (Yutopar), 40 mg/day
( ) True ( ) False
b) Magnesium chloride, 1 g twice daily
( ) True ( ) False

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c) Checking for cervical dilation
beginning in the middle of the
second trimester
( ) True ( ) False
d) Amniocentesis
( ) True ( ) False

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At 31 weeks, the patient presents with
strong contractions occurring at 6
minute intervals; the contractions got
progressively stronger while she was
traveling to the hospital to be examined.
Palpation confirms the strong
contractions. Fundal height
measurement and previous ultrasound
determinations confirm the dates and
size as appropriate for 31 weeks.

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Ultrasonography now indicates
moderate polyhydramnios. The cervix is
50% effaced and 1 cm dilated.
Appropriate measures to delay labor
would include which of the following?:
a) Intravenous alcohol.
( ) True ( ) False

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b) Intravenous magnesium sulfate.
( ) True ( ) False
c) An angiotensin converting enzyme
inhibitor.
( ) True ( ) False
d) A beta-adrenergic agent.
( ) True ( ) False

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e) Fluid restriction.
( ) True ( ) False
f) Artificial rupture of the membranes.
( ) True ( ) False

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Case # 185
A 2l-year-old African-American male
comes to your office with intense pain in
his right eye of several hours' duration
and a feeling that there is "something
scratchy in my eye." The pain began
while the patient was at work,
hammering on a piece of metal in the
process of making wheel rims for
automobiles.

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He does not recall any sensation of metal
fragments striking his eye. He was not
wearing safety glasses or contact lenses at
the time. Your examination shows right
conjunctival hyperemia with increased
tearing and mild blepharospasm. Staining
with fluorescein reveals an abrasion of
the right cornea on the nasal side of the
pupil, approximately 3 mm in size. The
abrasion is slightly irregular in shape, and
no foreign body is seen. Examination of
the left eye is unremarkable.

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Further initial diagnostic studies should
include:
a) Examination of the right eye under
general anesthesia.
( ) True ( ) False
b) Digital pressure on the right eye to
see if pain increases.
( ) True ( ) False

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c) A radiograph of the right eye.
( ) True ( ) False
The initial diagnostic evaluation reveals
no abnormalities other than the obvious
abrasion. Therapy at this time should
include:
a) A topical anesthetic to be used every
3-4 hours.
( ) True ( ) False

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b) A topical steroid in the right eye.
( ) True ( ) False
c) A systemic antibiotic.
( ) True ( ) False

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The patient returns in 48 hours and is
still complaining of a " scratchy "
sensation and pain with blinking .
Examination of the eye reveals the
corneal defect to be basically unchanged
or just slightly smaller than at the initial
examination.
At this time, proper management
includes:

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a) A topical steroid for the next 48 hours
and reexamination.
( ) True ( ) False
b) A topical anesthetic for 48 hours and
reexamination.
( ) True ( ) False
c) Referral to an ophthalmologist.
( ) True ( )False

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Case # 186
A 45-year-old white businessman
consults you after a blood bank refused
his blood donation because of
elevated blood pressure. During your
evaluation, you find fluctuating levels of
elevated blood pressure on several serial
determinations.

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Laboratory studies are normal except for
an elevated mean corpuscular volume
(MCV), which might suggest:
a) Pheochromocytoma.
( ) True ( ) False
b) Pernicious anemia.
( ) True ( ) False

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c) Hypothyroidism.
( ) True ( ) False
d) Alcoholism.
( ) True ( ) False
e) Hyperaldosteronism.
( ) True ( ) False

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Two weeks later, the patient is brought
to the emergency department because
he fell while inebriated. He has rib
fractures and a pneumothorax, and is
hospitalized with a chest tube in place.
On the second day of hospitalization, he
shows signs of agitation and you
consider the diagnosis of alcohol
withdrawal.

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Which additional signs and symptoms
would support this diagnosis?:
a) Tachycardia.
( ) True ( ) False
b) Abdominal cramping.
( ) True ( ) False
c) Tremor.
( ) True ( ) False

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d) Hallucinations.
( ) True ( ) False
e) Seizures.
( ) True ( ) False
e) Lacrimation and rhinorrhea.
( ) True ( ) False

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The diagnosis of delirium tremens (DTs)
is suggested when symptoms progress to
which of the following:
a) Ataxia.
( ) True ( ) False
b) Severe tremor
( ) True ( ) False

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c) Severe confusion and disorientation.
( ) True ( ) False

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Case # 187
A 73-year-old white female comes to
your office with a 2-day history of
severe, relentless back pain.
There is no history of trauma. Pain on fist
percussion is elicited over the mid -
thoracic spine. Pain is also elicited by
pushing downward on the patient's
shoulders while she is sitting.

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In addition to radiographs of her
spine, measures that you would consider
essential for evaluating the patient at
this visit include:
a) Neurologic examination of the lower
extremities.
( ) True ( ) False
b) Lumbar puncture
( ) True ( ) False

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c) Dual-photon densitometry.
( ) True ( ) False
The radiographs show relatively lucent
vertebral bodies, with accentuation of
their cortical outlines. A vertebral body
compression fracture with anterior
wedging is noted at T8. With this
additional information, you are now
particularly interested in uncovering
potential predisposing or etiologic
factors for her problem.

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Findings that would be important in this
regard include which of the following?:
a) Gout.
( ) True ( ) False
b) Chronic corticosteroid use.
( ) True ( ) False
c) 50-pack-year cigarette use.
( ) True ( ) False

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Additional studies indicated include:
a) Serum calcium.
( ) True ( ) False
b) Thyroid function.
( ) True ( ) False
c) Creatinine clearance determination.
( ) True ( ) False

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Your evaluation uncovers no other
problems. Acute management should
now include:
a) Analgesics.
( ) True ( ) False
b) Referral to an orthopedist.
( ) True ( ) False

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c) Transcutaneous nerve stimulation.
( ) True ( ) False

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Case # 188
Six months ago, a healthy 46-year-old
white male computer programmer had a
chemistry profile performed at his place
of employment and it showed an AST
(SGOT) level of 160 U /L (N 7- 27) .He has
not come to see you until now because
he has "just been too busy. " The report
shows normal results for total
bilirubin, alkaline phosphatase, creatine
kinase, glucose, creatinine, and

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You obtain a history significant for
consumption of raw oysters several
times a year and one blood
transfusion, 6 years ago. His history is
negative for foreign travel, alcohol or
other drug use, family history of liver
disease, sexual activity with other
men, symptoms of systemic illness, and
gastrointestinal complaints. He has not
received any hepatitis immunizations.
His physical examination is normal.

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True statements regarding this situation
include which of the following?:
a) Hemochromatosis may present in this
way.
( ) True ( ) False
b) The test results suggest biliary
obstruction.
( ) True ( ) False

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c) Elevated AST may be a normal finding
in men with a large muscle mass.
( ) True ( ) False
d) Steatohepatitis could cause this
enzyme pattern.
( ) True ( ) False

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You obtain further laboratory tests with
the following results:
Hepatitis B surface antigen....negative
Hepatitis B surface antibody...positive
Hepatitis B core antibody. ......positive
Hepatitis A antibody………. IgG positive
IgM negative
From these tests you can tell the patient
that:

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a) He has had hepatitis A in the past.
( ) True ( ) False
b) He has either chronic active or
chronic persistent hepatitis B.
( ) True ( ) False
c) He received blood contaminated
with hepatitis B 6 years ago.
( ) True ( ) False

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d) He is not currently infectious with
hepatitis B.
( ) True ( ) False

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Additional studies show normal serum
ceruloplasmin, ferritin, and alpha1-
antitrypsin levels. Findings are normal on
hepatic ultrasonography. A liver biopsy
shows changes of chronic hepatitis.
Antibody to hepatitis C is positive .
True statements you could make to the
patient include which of the following?:

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a) There is currently no treatment for
hepatitis C.
( ) True ( ) False
b) He is no longer contagious for
hepatitis C.
( ) True ( ) False

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c) Hepatitis C antibodies are found in
the majority of patients with non-A,
non-B hepatitis.
( ) True ( ) False

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That’s it, folks !

65. Gracias por su atención
Dr. Juan Carlos Díaz Torre
Pediatra Neonatólogo
dr_diaz_torre@hotmail.com
(779) 100 – 40 - 26
DR.JCDT
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