This document contains several clinical case summaries presented as questions with multiple choice answers. The cases cover topics including a patient presenting with hives, a post-surgery complication, a patient with joint swelling and chronic gout, and a pregnant patient with SLE and high blood pressure. For each case, the correct answer is provided to identify the underlying mechanism, appropriate treatment, most likely diagnosis, or best next test.

1. CLINICAL CASES
CASOS CLÍNICOS
DR. JCDT
Dr. Juan Carlos Díaz Torre
Pediatra Neonatólogo
dr_diaz_torre@hotmail.com
(779) 100 - 40 - 26 1

2. Page 223
A 42 year old male comes in with a history
of recurrent episodes of hives over the
past 5 day that are intensely pruritic on
DR. JCDT
the arms, chest, and back. He has a
medical histoy of Diabetes Type
II, coronary artery disease and a recent
urinary tract infection. His medications
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3. include glucophage, lisinopril, baby
aspirin and trimethoprim –
sulfamethoxazole. He has applied over
the counter Calamine lotion and has been
taking Benadryl without much relief. He
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denies any new use of soaps or products
and has not been out of the country
recently. He is not in contact with any
plants or chemicals at work.
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4. Question:
What is the mechanism of
hypersensitivity in this case.
Answers:
DR. JCDT
a) Overabundance of IgA.
b) Overabundance IgG.
c) Prostanglandin synthesis.
d) Mas cell degranulation.
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5. Page 210
A 75 years old female is evaluated for
refux esophagitis. At endoscopy the
mucosa is salmon pink with a definite
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demarcation between normal and
abnormal esophageal mucosa. Biopsy
indicates no dysplasia. Three weeks
following a Nissen Fundoplication, the
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6. patient has a severe episode of retching
following a heavy meal and has been
vomiting with blodd. Two hours later, he
has severe epigastric pain and a spiking
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temperature of 102 F.
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7. Question:
Which of the following is the problem?
Answers:
a) The Nissen has slipped.
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b) Fundoplication disruption has
occurred with perforation.
c) A perforated ulcer has developed.
d) Acute pancreatitis.
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8. Page 222
A 76 year old black male with a history
of chronic gout, on uric acid lowering
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therapy and severe Class IV renal
disease presents with multiple swollen
joints. Aspiration of his knee reveals uric
acid crystals intracellularly.
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9. Question:
What is the most appropriate therapy
for him a this time?
DR. JCDT
Answers:
a) Start indomethacin.
b) Start prednisone.
c) Discontinue allopurinol.
d) Start febuxastat. 9

10. Page 215
A 48 year old man presents with
hemoptysis. He reports that he has also
had bloody nasal discharge over the past
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month. His CXR shows bilateral nodules.
Laboratory data is notable for creatinine
of 4.7 mg/dl, and urine analysis shows
250 RBC/hpf.
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11. Question:
Which of the following serum studies
should be ordered next?
Answers:
a) ANCA, anti-GBM antibodies.
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(AntiNuclear Cytoplamic Antibodies, Glomerular Basement Membrane Antibodies)
b) Anti-dis-DNA and anti-cardiolipin
antibodies.
C) ESR, C3, C4 levels.
D) RF, anti-citrulline antibodies. 11
(Rheumatoid Factor)

12. Page 211
A 46 year old male has had intermittent
flares of ulcerative pancolitis for 10 years.
He has increasing diarrhea, blood per
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rectum, and fever. He responds to medical
management.
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13. Question:
Proctocolectomy is indicated for?
Answers:
a) Length of colon involved.
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b) Long periods of persistent disease.
c) Severe dysplasia on initial biopsy.
d) Persistent stricture.
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14. Page 218
A 46 year old woman with a history of
asthma calls you for a refill of her
albuterol inhaler. Her asthma has always
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been well-controlled on a daily dose of
moderate-dose inhaled corticosteroid and
she´s long misplaced her albuterol inhaler.
However 3 weeks ago she had an upper
respiratory tract infection. 14

15. All her acute symptoms have resolved but
since then she has felt more
wheezing, and often coughs at night.
She’s been using her daughter’s albuterol
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inhaler and finally decides to call you to
get her own prescription.
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16. Question:
What is the next appropriate step in
management?
Answers:
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a) Prescribe a course of oral
fluoroquinolone.
b) Prescribe albuterol inhaler for as
needed rescue use.
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17. c) A short course of oral corticosteroid
therapy.
d) Double her moderate-dose inhaled
corticosteroid therapy.
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18. Page 212
A 75 year old woman suffered from
sudden onset left eye blindness. No pain
was associated with her blindness, and no
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other abnormalities were seen in the
neurological examination.
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19. Question:
What is the most likely diagnosis?
Answers:
a) Small lacunar stroke involving the
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occipital lobe.
b) Ischemic lesion involving the lateral
geniculate nucleus.
19

20. a) Compressive lesion on the optical
chiasm.
b) Retinal ischemia due to retinal
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artery occlusion.
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21. Page 213
A 25 year old man with HIV presented to
the ED with right-sided weakness and
confusion. An MRI of the brain showed a
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few ring enhancing lesions. The
differential diagnosisis narrowed to
toxopasmosis and primary CNS
lymphoma.
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22. Question:
What is the appropriate next step
management?
Answers:
a) Open brain biopsy.
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b) Stereotactic brain biopsy.
c) Empiric treatment of toxoplasmosis
with reimagining to evaluate the
response.
d) High dose steroids. 22

23. Page 215
A 65 year old male with pneumonia and
septic shock develops acute kidney injury.
He has been running a low blood pressure
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(80/45 mmHg) on several vasopressor
agents. Urine output start to fall and his
creatinine begins to rise. His urine sodium
is high; he has no proteinuria.
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24. Question:
The most common cause of his kidney
failure in this setting is:
Answers:
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a) Obstruction.
b) Acute tubular necrosis.
c) Acute interstitial nephritis.
d) Goodpasture´s disease.
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25. Page 220
A 32 year old white female with systemic
lupus erythematosus is 32 weeks
pregnant and presents to your office with
a headache. Physical examination is
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remarkable for a blood pressure of
200/110 mmHg. Laboratory studies show
a hemoglobin of 8.0 g/dl, platelet count
of 38,000, a low haptoglobin level, and an
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elevated LDH, AST and ALT.

26. Question:
What test should be best to determine
the cause of her problems?
Answers:
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a) Complement levels.
b) Erythrocyte sedimentation rate.
c) Anti-Smith antibody.
d) C-reactive protein.
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27. Gracias por su atención
DR. JCDT
Dr. Juan Carlos Díaz Torre
Pediatra Neonatólogo
dr_diaz_torre@hotmail.com
(779) 100 - 40 - 26
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