This document contains 120 clinical cases presented by Dr. Juan Carlos Díaz Torre, a pediatric neonatologist. Each case presents a patient scenario or medical issue and asks the reader to choose the most appropriate response from a list of options. The cases cover a wide range of topics in pediatrics, obstetrics/gynecology, family medicine and internal medicine.

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
(10)
Dr. Juan Carlos Díaz Torre
Pediatra Neonatólogo
dr_diaz_torre@hotmail.com
(779) 100 - 40 - 26
DR.JCDT
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CASE # 101
A 35-year-old white female presents with
a 6-month history of irregular menstrual
bleeding. Before this problem began, her
periods occurred every 30 days and lasted
5 days. Now they occur every 20 days and
last for 10 days, and are heavier than they
were previously.

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A physical examination reveals no
obvious anatomic source of bleeding,
and a Papanicolaou (Pap) test is normal.
A pregnancy test is negative and a blood
workup for organic causes of irregular
menses is also negative. She takes no
medications.
Which one of the following would be
most appropriate at this point?

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A) Reassurance that the problem will
resolve on its own
B) Changing to a progesterone-only
contraceptive
C) Increasing the dosage of the oral
contraceptive
D) Pelvic ultrasonography

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CASE # 102
Which one of the following is true
regarding the risk of physical spouse
abuse?
a) It increases with alcohol and
substance abuse
b) It decreases when a woman exits an
abusive relationship

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c) It is higher among patients from
racial minorities
d) It increases as socioeconomic status
rises
e) It decreases during pregnancy

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CASE # 103
Which one of the following causes
rhinitis medicamentosa with prolonged
use in the treatment of rhinitis?
a) Intranasal decongestants
b) Intranasal antihistamines

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c) Intranasal anticholinergics
d) Intranasal mast cell stabilizers
e) Leukotriene antagonists

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CASE # 104
An 83-year-old female presents to your
office as a new patient. She recently
moved to the area to be closer to her
family. A history reveals that she has
been in excellent health, has no
complaints, and is on no medications
except occasional acetaminophen for
knee pain. She has never been in the
hospital and has not had any operations.
She says that she feels well.

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The examination is normal, with
expected age-related changes, except
that her blood pressure on three
different readings averages 175/70 mm
Hg. These readings are confirmed on a
subsequent follow-up visit. In addition
to lifestyle changes, which one of the
following would be most appropriate for
the initial management of this patient’s
hypertension?

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a) An alpha-blocker
b) A thiazide diuretic
c) An angiotensin receptor blocker
d) An ACE inhibitor
e) A beta-blocker

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CASE # 105
Surgery for obesity would be most
appropriate for which one of the
following?
a) A 37-year-old African-American
female who has failed multiple
diets, has no coexisting medical
problems, and has a BMI of 38

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b) A 43-year-old African-American male
with type 2 diabetes mellitus who
has failed multiple diets and has a
BMI of 38
c) A 31-year-old white male who has lost
50 lb on his diet and improved his
sleep apnea,hypertension, and
diabetes mellitus, but still has a BMI
of 42

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d) A 45-year-old white female with a
history of depression and alcohol
abuse who has failed multiple diets
and has a BMI of 40

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CASE # 106
A 22-year-old gravida 2 para 1 presents
to your office with a 1-day history of
vaginal bleeding and abdominal pain.
Her last menstrual period was 10 weeks
ago, and she had a positive home
pregnancy test 6 weeks ago. She denies
any passage of clots.

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On pelvic examination, you note blood in
the vaginal vault. The internal cervical os
is open.
Which one of the following best
describes the patient’s current condition?

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a) Completed abortion
b) Threatened abortion
c) Incomplete abortion
d) Inevitable abortion
e) Missed abortion

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CASE # 107
A 34-year-old white female visits your
office with a chief complaint of pelvic
pain that intensifies with her menstrual
period. She has a history of pain during
intercourse, which started in her mid-
twenties and has gradually become
worse. She reports recently missing some
work during her menstrual period due to
the pain.

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She has had two uneventful deliveries
and the pain was absent during and after
each pregnancy, but gradually returned.
She and her husband do not wish to
have any more children and her husband
has had a vasectomy. The patient denies
vaginal discharge or fever and a review
of systems is negative.

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A complete physical examination is
normal except for moderate nonspecific
tenderness on pelvic examination. In
addition, her uterus is moderately
retroverted and has decreased mobility.
Which one of the following would be the
most appropriate initial step in the
management of this patient?

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a) A complete hysterectomy and bilateral
oophorectomy
b) Conjugated estrogens (Premarin)
c) Depot medroxyprogesterone acetate
(Depo-Provera)
d) Contraceptives
e) Danazol (Danocrine)

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CASE # 108
A 62-year-old male presents for surgical
clearance prior to transurethral resection
of the prostate. His past history is
significant for a pulmonary embolus after
a cholecystectomy 15 years ago. His
examination is unremarkable except that
he is 23 kg (50 lb) overweight.

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The most appropriate recommendation
to the urologist would be to:
a) Place the patient on 650 mg of
aspirin daily prior to surgery
b) Start warfarin (Coumadin) after
surgery with a goal INR of 1.5

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c) Start the patient on subcutaneous
enoxaparin (Lovenox), 40 mg 1–2 hr
prior to surgery and once a day after
surgery
d) Cancel the surgery indefinitely
e) Start intravenous heparin according to
a weight-based protocol 24 hours
after surgery

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CASE # 109
A 28-year-old white female sees you for
preconception counseling. For the past 3
years she has been successfully treated
with fluoxetine (Prozac) for depression,
and she asks if she can continue taking it
when she becomes pregnant. It is labeled
by the FDA as category C for use in
pregnancy.

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Which one of the following would you
advise?
a) Animal studies do not indicate any
risk to the fetus; there are no studies
in women
b) Animal studies demonstrate some
risk to the fetus; there are no studies
in women

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c) Controlled studies in women fail to
demonstrate risk to the fetus; it is
safe to continue it
d) There is evidence of harm to the
human fetus, and she should
discontinue it
e) There is evidence of risk to the
human fetus

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CASE # 110
Which one of the following is most
predictive of increased perioperative
cardiovascular events associated with
noncardiac surgery in the elderly?

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a) An age of 80 years
b) Renal insufficiency (creatinine 2.0
mg/dL)
c) Left bundle-branch block
d) A history of previous stroke
e) Atrial fibrillation with a rate of 80
beats/min

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CASE # 111
Which one of the following statements
regarding varicoceles is true?
a) The incidence of varicoceles in adult
males is <5%
b) Varicoceles usually begin between 5
and 8 years of age

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c) A unilateral varicocele on the right
side should be referred for further
evaluation
d) Most varicoceles are bilateral
e) Repair of varicoceles usually results
in infertility

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Case # 112
A 2-year-old white female is brought to
your office by her parents, who are
concerned about the child’s “flat feet.”
On evaluation, the child’s feet are flat
with weight-bearing, but with toe
standing and with sitting the arch
appears.
You would:

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a) Reassure the parents
b) Recommend surgery
c) Recommend foot-stretching
exercises
d) Recommend orthotics
e) Recommend casting

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Case # 113
When a woman less than 50 years of age
develops vulvar cancer, which one of the
following associated conditions is most
frequently present?

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a) Lichen sclerosus
b) Syphilis
c) Human papillomavirus
d) Lymphogranuloma venereum
e) Diabetes mellitus

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Case # 114
A 35-year-old white male with known
long QT syndrome has a brief episode of
syncope requiring
cardiopulmonary resuscitation. Which
one of the following is most likely
responsible for this
episode?:

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a) Asystole
b) Atrial flutter with third degree block
c) Sinus tachycardia
d) Torsades de pointes

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Case #115
Which one of the following is associated
with a reduced risk of postmenopausal
osteoporosis?
a) Diuretic use
b) Cigarette smoking

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c) Low BMI
d) Corticosteroid use
e) Asian ethnicity

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Case # 116
Which one of the following is true
regarding herbal medications?
a) Manufacturers may claim their
products are effective for disease
treatment

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b) They must be approved by the
FDA before marketing?
c) If safety concerns arise, the FDA
must prove the product is unsafe
d) The use of herbal medicines is now
decreasing in this country

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Case # 117
A 59-year-old female with type 2
diabetes develops a 2×1-cm ulcer on the
plantar aspect of her right foot. The ulcer
is very deep and there is surrounding
cellulitis. A plain film is normal.

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Which one of the following would be the
imaging study of choice to rule out
osteomyelitis in this patient?:
a) A leukocyte scan
b) A CT scan

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c) Angiography
d) An MRI scan
e) A PET scan

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Case # 118
An 83-year-old female is admitted to the
hospital with an exacerbation of her
COPD. On the second hospital day she is
clinically improved but is quite
disoriented, experiencing visual
hallucinations, agitation, and problems
with recent memory and attention span.

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She is noted by the nursing staff to
periodically fall asleep during
conversation. Her previous medical
history is notable for emphysema and
hypertension, but there is no history of
psychiatric problems. Her blood pressure
is 140/82 mm Hg, pulse 88 beats/min,
and oxygen saturation 98% on 2 L of
nasal oxygen.

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Which one of the following does this
patient most likely have?:
a) Schizophrenia
b) Mania

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c) Acute depression
d) Delirium
e) Dementia

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Case # 119
A 31-year-old white female presents
with her third stress fracture of a lower
extremity in the past 4 years. Her history
and examination are otherwise
unremarkable except for a controlled
seizure disorder. The most likely cause of
her bone problem is:

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a) Hypothyroidism
b) Addison’s disease
c) Anticonvulsive medication
d) Osteogenesis imperfecta

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Case # 120
A 25-year-old female has unprotected
intercourse and chooses to use Plan B
(two 0.75 mg tablets of levonorgestrel,
taken 12 hours apart) as a form of
emergency contraception.

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Plan B has been shown to:
a) Prevent implantation, ovulation,
and fertilization
b) Protect against sexually transmitted
diseases

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c) Be teratogenic to an already
established pregnancy
d) Be effective only if used within 24
hours of unprotected intercourse
e) Be an effective routine contraceptive

55. 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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