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39-year-old male with a history of back pain

Patient: 39-year-old male with a history of back pain

Chief Complaint: Patient brought to the emergency department via ambulance due to decreased

level of consciousness, nausea and vomiting

History of Present Illness: Patient had history of spinal fusion secondary to spinal injury

approximately 2-3 years prior to this admission. He subsequently had a history of severe chronic

back for which he had been prescribed a variety of narcotic analgesics and muscle relaxants. He

had been prescribed methadone 1 month prior to admission, but ran out over a weekend and began

taking previously prescribed medications. According to family members, he took an estimated 12

hydrocodone/acetaminophen pills and 6 carisoprodol pills per day for the 3 days immediately prior

to this admission.

Social history: The patient’s family claimed he had no history of acute or chronic alcoholic abuse.

Physical examination: The patient appeared mildly confused and diaphoretic and was noted to

have mild tremors.

Principal Laboratory findings: See Table 1 below.

Patient Outcome: Patient deteriorated rapidly. Developed DIC and acute renal failure. On the 4 th

hospital day, he developed cardiopulmonary arrest and multi-organ failure leading to death.

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Case 1 – Table 1

Question 1 – At admission, what are this patient’s most striking laboratory results?

Question 2 – What is the significance of the patient’s elevated serum amylase and lipase on the

second hospital date?

Question 3 – Based on admission results, what is this patient’s most likely diagnosis?

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Case Study 2

Patient: 45-year-old African American woman

Presentation: Sudden death

History of Present Illness: The decedent was found unresponsive in bed one morning. She was

transported to the hospital, could not be revived and was pronounced dead a few minutes after

arrival.

Past medical/surgical history: Medications prescribed to the decedent suggested a past history of

hypertension. The decedent was treated previously for TB and 3 years after this treatment, a

cavitary lung lesion was found. Subsequently, 3 sputum samples were obtained and examined by

Ziehl-Nielsen staining for acid-fast bacilli. No AFB were observed, however a purified protein

derivative (PPD) test was strongly positive at this time. The patient was treated with 4-drug therapy

(isoniazid, rifampin, ethambutol, and pyrazinamide). Several years prior to this most recent hospital

admission, the decedent underwent an open reduction of a mandibular fracture and repair of a facial

laceration following facial trauma with a tire iron. She was left with a residual facial nerve palsy.

Social History: The decedent was single with 1 adult daughter. She had a history of alcohol and

drug abuse and had been a heavy smoker.

Autopsy Findings: The decedent’s body was that of an obese (247 lbs) African-American woman

with medium brown skin. The heart was not enlarged with respect to body size. The lungs were

normal in weight and configuration. The right lung was adherent to the diaphragm and a single,

minute granuloma without necrosis was seen only on microscopic examination. The adrenal glands

were enlarged bilaterally with a thick, nodular cortex and a firm yellow-tan cut surface and a focal

calcification was evident in both glands. The right lobe of the liver contained a 2-cm subcapsular

nodule beneath the surface. Microscopically, the adrenal glands were nearly completely destroyed

by granulomatous inflammation with caseating necrosis. Microscopic examination of the liver and

peritoneal nodules revealed that these nodules were granulomas. Staining of these tissues for acid-

fast bacilli and for fungi was negative.

Additional History: After discussing the autopsy findings with the decedent’s daughter, she

mentioned that the mother’s skin had been getting darker in the months preceding her death.

Principal Laboratory Findings: See Table 1 below.

Case 2 – Table 1

Test Patient’s Result Reference Interval

Vitreous Fluid

Sodium

Potassium

Serum

Cortisol

127

10.3

4

1.5-2.5 hours post-mortem

135-151 mEq/L

4.2-7.0 mEq/L

10-25 µg/dL

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Question 1 – What is the most likely diagnosis consistent with this patient’s autopsy histopathologic

findings?

Question 2 – What is the relationship between TB and the disease identified in question 1?

Case Study 3

Patient: 20-year-old African American woman

Chief complaint: Fever (102) and cough that were not responding to amoxicillin treatment.

Patient was lethargic and wheel chair bound.

History of present illness: Four days prior to presentation at the ER, the patient’s mother noticed

her daughter’s cough and fever. The patient was seen by a primary care physician who prescribed

amoxicillin. However, despite 4 days of treatment with amoxicillin, the patient showed no signs of

improvement.

Past Medical History: Neurological problems due to meningitis at 3 months of age.

Family/Social History: Non-contributory, no history of illicit drug, ethanol, or tobacco use.

Current medications: Depakote (valproic acid 250mg bid) for seizures.

Physical Exam Findings: Non-ambulatory (wheel chair bound), resists manipulation, was non-

verbal.

Principal Laboratory Findings: See Table 1 below.

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Case 3 – Table 1

Question 1 – What is (are) this patient’s most striking clinical and laboratory findings?

Question 2 – What is this patient’s most likely diagnosis?

Question 3 – What are the appropriate specimen collection and handling procedures for ammonia

testing?

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Case Study 4

Patient: 42-year-old African American man.

History of Present Illness: The police found him lying naked in a ditch, the victim of an apparent

assault. He had multiple signs of trauma, including numerous bruises and abrasions on his face and

extremities. He was conscious but was confused and combative.

Physical Examination: The patient’s vital signs were: temperature, 96.8; pulse 72 beats/min;

blood pressure, 131/88 mmHg. He could follow verbal commands but could not communicate. He

had a swollen upper lip and limitation in his ability to open his mouth. There was no evidence of

any other abnormalities. He was admitted to the hospital for further evaluation.

Past Medical History: Seven years ago, he was diagnosed with HIV/AIDS. In addition, he had

been treated for Pnemocystis carini (PCP) pneumonia 4 months prior to this current hospitalization

during which time his HIV viral load was 330,000 copies.

Principal Laboratory Findings: See Table 1 and 2 below.

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Case 4 – Table 1

Case 4 – Table 2

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Question 1 – What are this patient’s most striking lab findings?

Question 2 – What is the most likely explanation for this patient’s extremely low and undetectable

creatinine levels?

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