1. CLINICAL CASES
CASOS CLÍNICOS
Dr. Juan Carlos Díaz Torre
Pediatra Neonatólogo
dr_diaz_torre@hotmail.com
(779) 100 - 40 - 26
DR.JCDT
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Page 222
A 69 year old morbidly obese white
female states that she has severe
disabling right knee pain.
The pain has been ongoing for the past
two weeks and has been keeping her
awake at night.

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She does not recall any preceding trauma
and has been using a pillow between her
kness with some benefit.
Physical examination reveals crepitus and
mild tenderness of the knee with severe
pain 4 cm below the medial joint line.

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Question:
What is the most appropriate next step?
Answers:
a) X ray of the knee.
b) MRI of the knee.
c) Corticosteoid injection
d) Local supportive therapies.

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Page 217
A 60 year old man with severe COPD is
found to be difficult to arouse after
undergoing an outpatient, elective
screening colonoscopy. The following lab
data are available: ABG on room air
pH 7.24, PaO2 64, PaCO2 78, Electrolytes:
Na 140, HCO3 35, Cl 100.

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Question:
What is his current acid-base status?
Answers:
a) Metabolic acidosis with respiratory
compensation.
b) Acute respiratory acidosis with
metabolic compensation.
c) Acute on chronic respiratory
acidosis.
d) Chronic acidosis with metabolic
compensation.

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Page 212
A 51 year old male started to have a
gradual decline in his intellectual
functions associated with depressive
symptoms and personality changes. The
patient obtained a score of 23/30 on mini-
mental status examination and on
physical examination chorea was noted.
The diagnosis of Huntington’s disease was
suspected.

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Question:
What is typical inheritance pattern of
Huntington’s disease?
Answers:
a) X- linked.
b) Autosomal dominant.
c) Autosomal recessive.
d) No familial pattern.

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Page 220
A 24 year old female has diagnosed
Systemic Lupus Erythematosus for the
past 5 years. She has had episodes of
discoid rashes as well as polyarthritis and
mild hematologic abnormalities, but none
in the past year.

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Question:
What pharmacological agent would be
most appropiate for her?
a) Prednisone.
b) Hydrocloroquine.
c) Cyclophosphamide.
d) Metrotexate.

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Page 221
A 29 year old male has lower back pain
without radiation for the past 3 weeks. He
does not recall any specific instigating
event. Pain is severe and worse with
sitting, as well as standing. His
neurological examinations is
unremarkable.

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Question:
Which of the following is the most
appropriate action at this time?
Answers:
a) Check x-ray of his lower back.
b) Check an MRI of his lower back.
c) Start physical therapy and NSAID’s.
d) An EMG evaluation of his lower
extremities.

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Page 219
A 30 year old patient with Sjogren´s
syndrome is placed on a cytotoxic agent as
well as oral steroids. At 3 months she
begins tl have right thigh and knee pain
that is increased with walking and standing.
Physical examination reveals normal range
of motion of her knee, but mild pain on
internal and external rotation of her hip.

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Question:
What is the most sensitive and appropiate
test to diagnose his condition early?
Answer:
a) Plain film radiography.
b) Technetium-99m bone scanning.
c) Magnetic resonance imaging.
d) CT scan.

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Page 218
A 52 year old Hispanic female is seen in
consultation in the hospital. She states that
she has had a complete physical with
laboratory testing 2 months earlier that
was completely normal.
She feels poorly now for the past few
weeks. Her legs have become swollen and
she is having shortness of breath.

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Laboratory testing reveals a positive ANA
1:360, an elevated ds-DNA, low C3 and C4
levels, a 24 urine protein of 2.5 grams with
significant RBCs on her urinalysis, and renal
failure.
An echocardiogram shows a significant
pericardial effusion, but no evidence of
tamponade.
A kidney biopsy reveals diffuse proliferative
lupus nephritis.

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Question:
Which of tje following is the most appropiate
therapy at this time?
a) Cyclophosphamide.
b) Azothioprine.
c) Solumedrol.
d) Plasmaferesis.

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Page 218
A 48 year old man presents with a week of
fever, cough, and malaise. He has no
significant past medical history and he
takes no medications. His vital signs are
normal but an exam reveals right side
crackles. A CXR shows a right lower lobe
infiltrate.

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Question:
What antibiotic should be started?
a) Doxycycline.
b) Trimethoprim/Sulfametoxazole.
c) Cephalexine.
d) Amoxicilline/Clavulanate.

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Page 216
A 38 year old woman with a history of
asthma has had multiple admissions in the
past year for asthma exacerbation. She was
treated during the most recent
hospitalization for a community acquired
pneumonia that was seen on CXR. She
comes to you for post-discharge follow up.

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She reports she is compliant with her
combination steroid/long-acting beta
agonist inhaler, but still needs her rescue
inhaler several times a day, and still has a
cough occasionally productive of brown
plug.
Her blood work on the day of discharge
was only significant for an eosinophilic
count of 750/mm3.

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Question:
Which of the following should be
considered?
a) Chronic eosinophilic pneumonia.
b) Allergic broncopulmonary aspergillosis.
c) Steroid non responsive asthma.
d) Viral bronchitis.

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Page 213
A 32 year old primigravida presents to her
obstetrician for routine follow up at 34
weeks gestation. She has a sonogram of the
developing baby which also shows that she
has developed right sided moderate
hydronephrosis. Serum creatinine
concentration is checked and is 0.8 mg/dl.
She has no symptoms. Urinalysis is normal.

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Question:
At this point you should:
Answer:
a) Send urine for culture assuming
infection.
b) Consult Urology immediately.
c) Admit to the hospital.
d) No further intervention.

25. 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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