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Clinical cases (1) june 30, 13
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
(13)
Dr. Juan Carlos Díaz Torre
Pediatra Neonatólogo
dr_diaz_torre@hotmail.com
(779) 100 - 40 - 26
DR.JCDT
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3. DR.JCDT
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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.
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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.
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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
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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
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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.
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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?:
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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? :
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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
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Case # 164
Of the following, which one has the
greatest potential to spread via human-
to-human transmission?:
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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?
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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
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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.
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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?:
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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)
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Case # 167
The most appropriate initial
pharmacologic treatment of panic
disorder is:
a) Valproic acid (Depakene)
b) Lithium
c) An SSRI
d) A tricyclic antidepressant
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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.
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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
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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
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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.
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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?
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a) Urinary tract infection
b) Atypical pneumonia
c) Acute myeloid leukemia
d) Hodgkin’s lymphoma
e) Myocarditis
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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
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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
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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”.
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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:
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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
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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
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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
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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
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b) Has an irregular, notched border
( ) True ( ) False
c) Is mixed reddish-blue in color
( ) True ( ) False
d) Is pruritic
( ) True ( ) False
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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
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b) 8,000 rad local radiation
( ) True ( ) False
c) Regional node dissection
( ) True ( ) False
d) Fluoxymesterone (Halotestin), 10 mg
orally
( ) True ( ) False
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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.
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The etiology of peripheral neuropathy
includes
a) Toxic effects of antineoplastic
medications
( ) True ( ) False
b) Paraneoplastic syndrome
( ) True ( ) False
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Treatment options include
a) Chelation therapy
( ) True ( ) False
b) Carbamazepine (Tegretol)
( ) True ( ) False
c) Tricyclic antidepressants such as
amitriptyline (Elavil)
( ) True ( ) False
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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.
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Appropriate management at this time
would include
a) Emergency surgical consultation
( ) True ( ) False
b) CBC
( ) True ( ) False
c) Urinalysis
( ) True ( ) False
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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
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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.
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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
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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
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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.
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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? :
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a) An MRI to rule out Guillain-Barre
syndrome
( ) True ( ) False
b) A lumbar puncture to rule out a
cerebrovascular accident
( ) True ( ) False
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c) A doxycyline challenge for tick
paralysis
( ) True ( ) False
d) A psychiatric consultation for
hysteria
( ) True ( ) False
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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
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b) Obtain psychiatric consultation
( ) True ( ) False
c) Begin intravenous ciprofloxacin
(Cipro)
( ) True ( ) False
d) Monitor respiratory status closely
( ) True ( ) False
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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.
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Appropriate diagnostic studies at this
time include which of the following?
a) Thyroid-stimulating hormone (TSH)
level
( ) True ( ) False
b) CBC
( ) True ( ) False
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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
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c) Endometrial ablation
( ) True ( ) False
d) Medroxyprogesterone acetate
(Provera), 5-10 mg daily 10 days of
each month
( ) True ( ) False
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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
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b) Prescribe combined estrogen and
progesterone therapy
( ) True ( ) False
c) Recommend dilatation and
curettage
( ) True ( ) False
d) Begin therapy with danazol
(Danocrine)
( ) True ( ) False
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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.
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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.
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Current medications likely contributing
to his altered mental state include which
of the following?
a) Lisinopril (Zestril)
( ) True ( ) False
b) Cimetidine (Tagamet)
( ) True ( ) False
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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
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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
