INGLES #2 (5 INTENTOS)

A 25 YEAR-OLD CAUCASIAN FARMER PRESENTS TO THE OUTPATIENT DEPARTMENT COMPLAINING OF A TWO MONTH HISTORY OF GENERALIZED ACHES AND JOINT PAINS. HE USED TO BE AN ACTIVE RUNNER BUT SAYS A HIP INJURY FORCED HIM TO GIVE UP COMPETITIVE RUNNING A YEAR AGO. TWO YEARS AGO HE WAS SEEN IN CASUALTY WITH A PAINFUL RED EYE FOR WHICH HE WAS TREATED WITH EYEDROPS. HE IS A HEAVY SMOKER OF 45 CIGARETTES A DAY AND CONSUMES FIVE PINTS OF BEER EVERY WEEKEND. HE DENIES ANY SKIN RASHES OR MUCOSAL ULCERATION. HIS MOTHER SUFFERED FROM RHEUMATOID ARTHRITIS AND HIS FATHER HAD SEVERE GOUT. ON EXAMINATION, THE LEFT FIRST METATARSOPHALANGEAL JOINT WAS SWOLLEN AND TENSE, BUT ALL THE OTHER JOINTS WERE UNREMARKABLE. ROTATION OF THE LUMBAR SPINE WAS RESTRICTED. WHAT IS THE MOST LIKELY DIAGNOSE IN THIS MAN?
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AN 18-YEAR-OLD LADY WAS DIAGNOSED WITH ACUTE LYMPHOBLASTIC LEUKAEMIA. AS PART OF THE CHEMOTHERAPY REGIMEN, SHE REQUIRED WEEKLY LUMBAR PUNCTURES TO ADMINISTER INTRATHECAL CHEMOTHERAPY. WHEN SHE ATTENDED THE DAY UNIT FOR HER THIRD COURSE OF TREATMENT, HER PLATELET COUNT WAS FOUND TO BE 25 X 109/L (150-400 X109/L). WHAT IS THE BEST COURSE OF ACTION?
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A 21-YEAR-OLD MAN WAS ADMITTED TO HOSPITAL FOLLOWING THE ONSET OF SHARP, LEFT-SIDED CHEST PAIN AND BREATHLESSNESS. ON EXAMINATION HE WAS MILDLY BREATHLESS AT REST. PULSE 100 BEATS PER MINUTE AND REGULAR; BLOOD PRESSURE 125/60 MMHG. HIS CHEST X-RAY SHOWED A LEFT PNEUMOTHORAX WITH A 4CM RIM OF AIR VISIBLE AROUND THE LEFT LUNG. HIS OXYGEN SATURATION ON AIR WAS 98%. WHAT IS THE MOST APPROPRIATE MANAGEMENT?
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A 40-YEAR-OLD MAN PRESENTS TO THE EMERGENCY DEPARTMENT COMPLAINING OF SEVERE SHORTNESS OF BREATH. THE BREATHLESSNESS HAS BEEN WORSENING OVER THE PAST FEW YEARS, AND THE PATIENT REPORTS GROWING TACHYPNEIC WITH MILD EXERTION, AND SOMETIMES EVEN AT NIGHT. ON EXAMINATION, HE HAS GENERALIZED EDEMA, JUGULAR VENOUS DISTENTION, AND HEPATIC DISTENTION. CARDIAC EXAMINATION SHOWS A RIGHT VENTRICULAR HEAVE, A RIGHT-SIDED S3, AND S4 WITH A PULMONARY EJECTION CLICK. A CHEST X-RAY FILM SHOWS CARDIOMEGALY AND WIDENING OF THE HILAR VESSELS, INCLUDING THE PULMONARY ARTERIES. AN ELECTROCARDIOGRAM SHOWS TALL, PEAKED P WAVES IN LEADS II, III, AND AVF, RIGHT AXIS DEVIATION, AND RIGHT VENTRICULAR HYPERTROPHY.
WHICH OF THE FOLLOWING IS THE MOST LIKELY DIAGNOSIS?
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55-YEAR-OLD BUILDER WAS REFERRED TO CLINIC WITH A SEVEN-MONTH HISTORY OF CENTRAL CHEST DISCOMFORT. HE DESCRIBED THE PAIN AS BEING CENTRAL AND ‘BURNING’ IN CHARACTER. THE PAIN FREQUENTLY OCCURRED AT NIGHT AND WAS ASSOCIATED WITH AN ACIDIC TASTE IN THE MOUTH. HE HAD FOUND SOME RELIEF BY TAKING OVER-THE-COUNTER ANTACID TABLETS AND HAD SEEN HIS GP, WHO PRESCRIBED A PROTON PUMP INHIBITOR. HOWEVER, DESPITE A TWO-MONTH COURSE OF OMEPRAZOLE, THE PATIENT WAS STILL EXPERIENCING FREQUENT EPISODES OF CHEST DISCOMFORT. HIS GP HAD ALSO SENT BLOOD FOR HELICOBACTER PYLORI SEROLOGY, WHICH WAS FOUND TO BE NEGATIVE. HE WAS OTHERWISE WELL AND DID NOT GIVE A HISTORY OF ANY WEIGHT LOSS, VOMITING OR DYSPHAGIA. THERE WAS NO OTHER PAST MEDICAL HISTORY OF NOTE. ON EXAMINATION, HE LOOKED WELL. HE WAS NOT CLINICALLY ANAEMIC. HIS PULSE WAS 80 BEATS PER MINUTE AND REGULAR WITH BLOOD PRESSURE OF 135/70 MMHG. HIS HEART SOUNDS WERE NORMAL AND THE CHEST WAS CLEAR. HIS ABDOMEN WAS SOFT AND NON-TENDER WITH NO PALPABLE
ORGANOMEGALY OR MASSES. A RECTAL EXAMINATION WAS UNREMARKABLE AND NORMAL STOOL WAS NOTED ON THE EXAMINATION GLOVE. AN OUTPATIENT UPPER GASTROINTESTINAL ENDOSCOPY WAS ARRANGED. THIS REVEALED A 10CM AREA AT THE LOWER OESOPHAGUS THAT HAD THE APPEARANCES OF NON-INFLAMED BARRETT’S EPITHELIUM. MULTIPLE BIOPSIES WERE TAKEN. THE HISTOLOGY WAS REPORTED AS COLUMNAR LINED MUCOSA WITH INTESTINAL METAPLASIA. NO DYSPLASIA SEEN. WHAT ADVICE SHOULD BE GIVEN?
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SERIAL CLINICAL CASE 1/3
A 23-YEAR-OLD MAN PRESENTS TO THE URGENT CARE CLINIC COMPLAINING OF SEVERE THROAT PAIN, FEVER, CHILLS, AND DIFFUSE JOINT PAINS. HE FIRST DEVELOPED SYMPTOMS TWO WEEKS AGO AND WAS EVALUATED BY ANOTHER PHYSICIAN AT THE SAME CLINIC. A THROAT CULTURE WAS DONE, AND THE PATIENT WAS GIVEN A PRESCRIPTION FOR ANTIBIOTICS THAT HE DID NOT FILL. HE NOW RETURNS WITH A WORSENING OF HIS SYMPTOMS. HE HAS SINCE DEVELOPED SEVERE JOINT PAIN AND SWELLING, WHICH FIRST AFFECTED HIS RIGHT WRIST, THEN SPREAD TO BOTH KNEES, AND NOW HAS ALSO AFFECTED HIS LEFT ANKLE. HE ALSO COMPLAINS OF MODERATE TO SEVERE CHEST DISCOMFORT AND SHORTNESS OF BREATH. HIS TEMPERATURE IS 38.7 C, BLOOD PRESSURE IS 118/86 MM/HG, PULSE IS 104/MIN, AND RESPIRATION RATE 20/MIN. THERE IS AN EXUDATE ON HIS OROPHARYNX AND BILATERAL ANTERIOR CERVICAL LYMPHADENOPATHY. ON LUNG EXAMINATION, THERE ARE BIBASILAR CRACKLES, AND THE CARDIAC EXAMINATION REVEALS TACHYCARDIA, BUT A NORMAL RHYTHM AND NO MURMURS OR RUBS. EXAMINATION OF HIS JOINTS REVEALS SYNOVITIS IN HIS RIGHT WRIST, LEFT ANKLE, AND BOTH KNEES.

WHICH OF THE FOLLOWING IS THE MOST LIKELY CAUSE OF THIS PATIENT’S CARDIAC FINDINGS?
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SERIAL CLINICAL CASE 2/3
A 23-YEAR-OLD MAN PRESENTS TO THE URGENT CARE CLINIC COMPLAINING OF SEVERE THROAT PAIN, FEVER, CHILLS, AND DIFFUSE JOINT PAINS. HE FIRST DEVELOPED SYMPTOMS TWO WEEKS AGO AND WAS EVALUATED BY ANOTHER PHYSICIAN AT THE SAME CLINIC. A THROAT CULTURE WAS DONE, AND THE PATIENT WAS GIVEN A PRESCRIPTION FOR ANTIBIOTICS THAT HE DID NOT FILL. HE NOW RETURNS WITH A WORSENING OF HIS SYMPTOMS. HE HAS SINCE DEVELOPED SEVERE JOINT PAIN AND SWELLING, WHICH FIRST AFFECTED HIS RIGHT WRIST, THEN SPREAD TO BOTH KNEES, AND NOW HAS ALSO AFFECTED HIS LEFT ANKLE. HE ALSO COMPLAINS OF MODERATE TO SEVERE CHEST DISCOMFORT AND SHORTNESS OF BREATH. HIS TEMPERATURE IS 38.7 C, BLOOD PRESSURE IS 118/86 MM/HG, PULSE IS 104/MIN, AND RESPIRATION RATE 20/MIN. THERE IS AN EXUDATE ON HIS OROPHARYNX AND BILATERAL ANTERIOR CERVICAL LYMPHADENOPATHY. ON LUNG EXAMINATION, THERE ARE BIBASILAR CRACKLES, AND THE CARDIAC EXAMINATION REVEALS TACHYCARDIA, BUT A NORMAL RHYTHM AND NO MURMURS OR RUBS. EXAMINATION OF HIS JOINTS REVEALS SYNOVITIS IN HIS RIGHT WRIST, LEFT ANKLE, AND BOTH KNEES.

WHAT UNDERLYING CONDITION CAN EXPLAIN THE PATIENT’S UPPER RESPIRATORY AS WELL AS CARDIAC AND JOINT SIGNS AND SYMPTOMS?
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SERIAL CLINICAL CASE 3/3
A 23-YEAR-OLD MAN PRESENTS TO THE URGENT CARE CLINIC COMPLAINING OF SEVERE THROAT PAIN, FEVER, CHILLS, AND DIFFUSE JOINT PAINS. HE FIRST DEVELOPED SYMPTOMS TWO WEEKS AGO AND WAS EVALUATED BY ANOTHER PHYSICIAN AT THE SAME CLINIC. A THROAT CULTURE WAS DONE, AND THE PATIENT WAS GIVEN A PRESCRIPTION FOR ANTIBIOTICS THAT HE DID NOT FILL. HE NOW RETURNS WITH A WORSENING OF HIS SYMPTOMS. HE HAS SINCE DEVELOPED SEVERE JOINT PAIN AND SWELLING, WHICH FIRST AFFECTED HIS RIGHT WRIST, THEN SPREAD TO BOTH KNEES, AND NOW HAS ALSO AFFECTED HIS LEFT ANKLE. HE ALSO COMPLAINS OF MODERATE TO SEVERE CHEST DISCOMFORT AND SHORTNESS OF BREATH. HIS TEMPERATURE IS 38.7 C, BLOOD PRESSURE IS 118/86 MM/HG, PULSE IS 104/MIN, AND RESPIRATION RATE 20/MIN. THERE IS AN EXUDATE ON HIS OROPHARYNX AND BILATERAL ANTERIOR CERVICAL LYMPHADENOPATHY. ON LUNG EXAMINATION, THERE ARE BIBASILAR CRACKLES, AND THE CARDIAC EXAMINATION REVEALS TACHYCARDIA, BUT A NORMAL RHYTHM AND NO MURMURS OR RUBS. EXAMINATION OF HIS JOINTS REVEALS SYNOVITIS IN HIS RIGHT WRIST, LEFT ANKLE, AND BOTH KNEES.

THE PATIENT CONTINUES TO DETERIORATE, HE DEVELOPS WORSENING HEART FAILURE, AND REQUIRES TRANSFER TO THE INÍENSIVE CARE UNIT FOR USE OF AN INOTROPIC AGENT TO INCREASE HIS CARDIAC OUTPUT. WHICH OF THE FOLLOWING AGENTS WOULD MOST
LIKELY BE USED?
END OF CLINICAL CASE.
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CASO CLÍNICO SERIADO 1/4

A 23-YEAR-OLD AFRO-CARIBBEAN MALE PRESENTED TO THE EMERGENCY DEPARTMENT WITH INTERMITTENT RIGHT UPPER ABDOMINAL PAIN. HE HAD A TEMPERATURE OF 38.50C AND HE WAS ICTERIC. INVESTIGATIONS SHOWED: HAEMOGLOBIN 11.2 G/DL (13.0-18.0) HAEMATOCRIT 0.36 (0.40-0.52) MCV 78 FL (80-96) WHITE CELL COUNT 10.2 X109/L (4-11 X109) HIS BLOOD FILM IS SHOWN BELOW: (PLEASE SELECT AN OPTION).

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CASO CLÍNICO SERIADO 1/2

A 78-YEAR-OLD MAN HAD BEEN PREVIOUSLY ACTIVE, BUT FOUND THAT HIS HEALTH WAS DECLINING. OVER A FOUR-MONTH PERIOD, HIS ABILITY TO PERFORM EVEN VERY MINIMAL EXERCISE, SUCH AS WALKING AROUND HIS YARD, DECLINED PRECIPITOUSLY. THE FAMILY TOOK HIM FROM DOCTOR TO DOCTOR, NONE OF WHOM WERE INITIALLY ABLE TO FIGURE OUT WHAT WAS WRONG WITH HIM. BECAUSE OF THE PATIENT’S AGE, MOST OF THE PHYSICIANS THAT THE FAMILY CONSULTED WERE UNWILLING TO DO MUCH OTHER THAN TO LISTEN TO THE FAMILY’S STORY AND THEN RUN A FEW SCREENING TESTS. IN SOME WAYS, HE ACTED AS IF HE WERE IN CONGESTIVE HEART FAILURE, BUT HE INITIALLY HAD NO EVIDENCE OF FLUID OVERLOAD AND HIS LUNGS WERE CLEAR. THE CARDIAC PROFILE ON CHEST X-RAY WAS SLIGHTLY ENLARGED. HIS ECG STUDIES WERE INTERPRETED AS WITHIN THE NORMAL RANGE FOR HIS AGE. ANGIOGRAPHY STUDIES SHOWED NO EVIDENCE OF SIGNIFICANT CORONARY ARTERY OCCLUSION. PULMONARY FUNCTION STUDIES WERE UNREVEALING.
FOLLOWING A THANKSGIVING MEAL, THE PATIENT’S CONDITION WORSENED MARKEDLY OVER THE NEXT FEW HOURS, AND HE WAS TAKEN TO AN EMERGENCY DEPARTMENT. AT THAT POINT, THE PATIENT WAS IN OBVIOUS, SEVERE, CONGESTIVE HEART FAILURE WITH EVIDENCE OF FLUID OVERLOAD AND PULMONARY EDEMA. INTRAVENOUS FUROSEMIDE WAS STARTED, WHICH OVER THE NEXT FEW HOURS MARKEDLY IMPROVED HIS CLINICAL CONDITION.
FUROSEMIDE IS CLASSIFIED AS WHICH OF THE FOLLOWING?
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CASO CLÍNICO SERIADO 2/2

A 78-YEAR-OLD MAN HAD BEEN PREVIOUSLY ACTIVE, BUT FOUND THAT HIS HEALTH WAS DECLINING. OVER A FOUR-MONTH PERIOD, HIS ABILITY TO PERFORM EVEN VERY MINIMAL EXERCISE, SUCH AS WALKING AROUND HIS YARD, DECLINED PRECIPITOUSLY. THE FAMILY TOOK HIM FROM DOCTOR TO DOCTOR, NONE OF WHOM WERE INITIALLY ABLE TO FIGURE OUT WHAT WAS WRONG WITH HIM. BECAUSE OF THE PATIENT’S AGE, MOST OF THE PHYSICIANS THAT THE FAMILY CONSULTED WERE UNWILLING TO DO MUCH OTHER THAN TO LISTEN TO THE FAMILY’S STORY AND THEN RUN A FEW SCREENING TESTS. IN SOME WAYS, HE ACTED AS IF HE WERE IN CONGESTIVE HEART FAILURE, BUT HE INITIALLY HAD NO EVIDENCE OF FLUID OVERLOAD AND HIS LUNGS WERE CLEAR. THE CARDIAC PROFILE ON CHEST X-RAY WAS SLIGHTLY ENLARGED. HIS ECG STUDIES WERE INTERPRETED AS WITHIN THE NORMAL RANGE FOR HIS AGE. ANGIOGRAPHY STUDIES SHOWED NO EVIDENCE OF SIGNIFICANT CORONARY ARTERY OCCLUSION. PULMONARY FUNCTION STUDIES WERE UNREVEALING.
FOLLOWING A THANKSGIVING MEAL, THE PATIENT’S CONDITION WORSENED MARKEDLY OVER THE NEXT FEW HOURS, AND HE WAS TAKEN TO AN EMERGENCY DEPARTMENT. AT THAT POINT, THE PATIENT WAS IN OBVIOUS, SEVERE, CONGESTIVE HEART FAILURE WITH EVIDENCE OF FLUID OVERLOAD AND PULMONARY EDEMA. INTRAVENOUS FUROSEMIDE WAS STARTED, WHICH OVER THE NEXT FEW HOURS MARKEDLY IMPROVED HIS CLINICAL CONDITION.

TWO HOURS LATER, YOU NOTE THAT THE HEART SOUNDS APPEAR DISTANT AND THEN YOU HAVE THE PATIENT LIE AT AN ANGLE OF 30 TO 45 DEGREES, AND DO A CAREFUL EXAMINATION OF THE RIGHT JUGULAR PULSE, WHICH YOU FIND VERY WORRISOME. THE PULSE IS BOTH VERY ELEVATED AND SHOWS DRAMATIC X AND Y DESCENTS. FURTHER, YOU NOTE THAT THE VENOUS DISTENTION PARADOXICALLY INCREASES DURING INSPIRATION.
THIS PATIENT MOST LIKELY HAS WHICH OF THE FOLLOWING?
END OF CLINICAL CASE.
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SERIAL CLINICAL CASE
A 50-YEAR-OLD MAN CONSULTS A PHYSICIAN BECAUSE HE HAS DEVELOPED A CHRONIC, NON-PRODUCTIVE COUGH AND IS EXPERIENCING A REDUCED ABILITY TO DO STRENUOUS WORK. HIS SYMPTOMS HAVE DEVELOPED INSIDIOUSLY. ON QUESTIONING, HE STATES THAT HE IS A SMOKER AND HAS ALSO WORKED AS A CONTRACTOR FOR ALL OF HIS ADULT LIFE. PHYSICAL EXAMINATION IS NOTABLE FOR THE PRESENCE OF REPETITIVE END-INSPIRATORY BASAL CRACKLES AND FINGER CLUBBING. A CHEST X-RAY FILM SHOWS DIFFUSELY DISTRIBUTED, SMALL IRREGULAR OPACITIES THAT ARE MOST PROMINENT IN THE LOWER LUNG ZONES. LOCALIZED AREAS OF PLEURAL
THICKENING ARE ALSO NOTED. NO LARGE MASSES ARE SEEN THE CHEST X-RAY FILM

IS MOST CONSISTENT WITH WHICH OF THE FOLLOWING?
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CASO CLÍNICO SERIADO 2/2

A 50-YEAR-OLD MAN CONSULTS A PHYSICIAN BECAUSE HE HAS DEVELOPED A CHRONIC, NON-PRODUCTIVE COUGH AND IS EXPERIENCING A REDUCED ABILITY TO DO STRENUOUS WORK. HIS SYMPTOMS HAVE DEVELOPED INSIDIOUSLY. ON QUESTIONING, HE STATES THAT HE IS A SMOKER AND HAS ALSO WORKED AS A CONTRACTOR FOR ALL OF HIS ADULT LIFE. PHYSICAL EXAMINATION IS NOTABLE FOR THE PRESENCE OF REPETITIVE END-INSPIRATORY BASAL CRACKLES AND FINGER CLUBBING. A CHEST X-RAY FILM SHOWS DIFFUSELY DISTRIBUTED, SMALL IRREGULAR OPACITIES THAT ARE MOST PROMINENT IN THE LOWER LUNG ZONES. LOCALIZED AREAS OF PLEURAL THICKENING ARE ALSO NOTED. NO LARGE MASSES ARE SEEN THE CHEST X-RAY FILM.

THE PATIENT’S WORK HISTORY IS MOST SUGGESTIVE OF EXPOSURE TO WHICH OF THE FOLLOWING?
END OF CLINICAL CASE
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SERIAL CLINICAL CASE 2/3
A 70-YEAR-OLD MAN IS SEEN BY HIS FAMILY PRACTICE PHYSICIAN DURING A ROUTINE OFFICE VISIT. THE MAN COMPLAINS OF NOT FEELING WELL FOR THE LAST THREE MONTHS. FURTHER QUESTIONING REVEALS THAT THE PATIENT HAS A CHRONIC, UNPRODUCTIVE COUGH THAT HE ATTRIBUTES TO AN OLD SMOKING HISTORY. PHYSICAL EXAMINATION IS NOTABLE FOR A 7 KG WEIGHT LOSS SINCE THE LAST OFFICE VISIT THREE MONTHS PREVIOUSLY. A MULTINODULAR INFILTRATE IS SEEN IN THE LUNG FIELD BEHIND AND ABOVE THE RIGHT CLAVICLE.
THE PATIENT IS INJECTED INTRADERMALLY WITH PPD. 3 DAYS AFTER THE INJECTION, THERE IS A 13-MM DIAMETER AREA OF INDURATION AT THE INJECTION SITE.

WHICH OF THE FOLLOWING PRINCIPALLY MEDIATES THIS FORM OF HYPERSENSITIVITY?
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SERIAL CLINICAL CASE 3/3
A 70-YEAR-OLD MAN IS SEEN BY HIS FAMILY PRACTICE PHYSICIAN DURING A ROUTINE OFFICE VISIT. THE MAN COMPLAINS OF NOT FEELING WELL FOR THE LAST THREE MONTHS. FURTHER QUESTIONING REVEALS THAT THE PATIENT HAS A CHRONIC, UNPRODUCTIVE COUGH THAT HE ATTRIBUTES TO AN OLD SMOKING HISTORY. PHYSICAL EXAMINATION IS NOTABLE FOR A 7 KG WEIGHT LOSS SINCE THE LAST OFFICE VISIT THREE MONTHS PREVIOUSLY. A MULTINODULAR INFILTRATE IS SEEN IN THE LUNG FIELD BEHIND AND ABOVE THE RIGHT CLAVICLE.
THE PATIENT IS INJECTED INTRADERMALLY WITH PPD. 3 DAYS AFTER THE INJECTION, THERE IS A 13-MM DIAMETER AREA OF INDURATION AT THE INJECTION SITE.

THE PRINCIPAL DRUG RECOMMENDED FOR TREATMENT OF THIS PATIENT’S DISEASE TARGETS WHICH OF THE FOLLOWING MOLECULES?
END OF CLINICAL CASE
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SERIAL CLINICAL CASE 2/2
A 60-YEAR-OLD MAN PRESENTS TO THE EMERGENCY DEPARTMENT COMPLAINING OF SHORTNESS OF BREATH, COUGH, AND COPIOUS SPUTUM PRODUCTION. HE STATES THAT HE HAS BEEN COUGHING FOR YEARS, AND HAS HAD INCREASED SPUTUM PRODUCTION FOR SEVERAL MONTHS EACH YEAR. ON EXAMINATION, HE IS OBESE, AFEBRILE, CYANOTIC, AND IN ACUTE DISTRESS. COARSE RALES ARE AUSCULTATED BILATERALLY AT THE LUNG BASES. HE SMOKES TWO PACKS OF CIGARETTES A DAY AND HAS A SEVENTY-FIVE PACK-YEAR SMOKING HISTORY. A CHEST X-RAY FILM APPEARS NORMAL, EXCEPT FOR SLIGHTLY ENLARGED LUNG FIELDS

WHICH OF THE FOLLOWING SPIROMETRY PROFILES WOULD MOST LIKELY BE SEEN IN THIS PATIENT?
END OF CLINICAL CASE.
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SERIAL CLINICAL CASE 2/3
A 72-YEAR-OLD WOMAN PRESENTS TO THE EMERGENCY DEPARTMENT WITH COUGH, FEVER, AND SHORTNESS OF BREATH. THE WOMAN LIVES ALONE AT HOME, BUT SPENDS PART OF EACH DAY SHOPPING AND RIDING PUBLIC BUSES. APPROXIMATELY 4 DAYS PREVIOUSLY SHE HAD DEVELOPED AN UPPER RESPIRATORY INFECTION.
APPROXIMATELY 2 DAYS AGO, SHE ABRUPTLY BECAME MUCH MORE ILL, AND HER SYMPTOMS STARTED WORSENING, BEGINNING WITH A SINGLE, LONG, SHAKING CHILL. SINCE THAT TIME, SHE HAS HAD FEVER, PAIN WITH BREATHING, COUGH, AND DYSPNEA. SHE DECIDED TO COME TO THE EMERGENCY DEPARTMENT WHEN HER TEMPERATURE AT HOME WAS 39.5. IN THE EMERGENCY DEPARTMENT, HER TEMPERATURE IS 39.9 C, BLOOD PRESSURE IS 90/50 MM HG, PULSE IS 120/MIN, AND RESPIRATIONS ARE 30/MIN. NO BREATH SOUNDS ARE HEARD OVER HER LOWER LEFT LUNG FIELD, BUT THEY CAN BE HEARD AT OTHER SITES. A CHEST X-RAY FILM WOULD BE MOST LIKELY TO DEMONSTRATE WHICH OF THE FOLLOWING:

GRAM’S STAIN OF A SMEAR FROM A SPUTUM SAMPLE DEMONSTRATES GRAM-POSITIVE LANCET-SHAPED DIPLOCOCCI IN SHORT CHAINS.
WHICH OF THE FOLLOWING WOULD MOST LIKELY BE IDENTIFIED AFTER CULTURING?
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SERIAL CLINICAL CASE 3/3
A 72-YEAR-OLD WOMAN PRESENTS TO THE EMERGENCY DEPARTMENT WITH COUGH, FEVER, AND SHORTNESS OF BREATH. THE WOMAN LIVES ALONE AT HOME, BUT SPENDS PART OF EACH DAY SHOPPING AND RIDING PUBLIC BUSES. APPROXIMATELY 4 DAYS PREVIOUSLY SHE HAD DEVELOPED AN UPPER RESPIRATORY INFECTION.
APPROXIMATELY 2 DAYS AGO, SHE ABRUPTLY BECAME MUCH MORE ILL, AND HER SYMPTOMS STARTED WORSENING, BEGINNING WITH A SINGLE, LONG, SHAKING CHILL. SINCE THAT TIME, SHE HAS HAD FEVER, PAIN WITH BREATHING, COUGH, AND DYSPNEA. SHE DECIDED TO COME TO THE EMERGENCY DEPARTMENT WHEN HER TEMPERATURE AT HOME WAS 39.5. IN THE EMERGENCY DEPARTMENT, HER TEMPERATURE IS 39.9 C, BLOOD PRESSURE IS 90/50 MM HG, PULSE IS 120/MIN, AND RESPIRATIONS ARE 30/MIN. NO BREATH SOUNDS ARE HEARD OVER HER LOWER LEFT LUNG FIELD, BUT THEY CAN BE HEARD AT OTHER SITES. A CHEST X-RAY FILM WOULD BE MOST LIKELY TO DEMONSTRATE WHICH OF THE FOLLOWING:

THE PATIENT’S INFECTION IS TREATED WITH PARENTERAL PENICILLIN, TO WHICH SHE PROMPTLY RESPONDS. THIS DRUG ACTS BY WHICH OF THE FOLLOWING MECHANISMS?
END OF CLINICAL CASE.
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SERIAL CLINICAL CASE 1/5
A 26-YEAR-OLD WOMAN COMPLAINS TO HER PHYSICIAN OF DISCOMFORT DURING INTERCOURSE. PELVIC EXAMINATION DEMONSTRATES A FROTHY, YELLOW-GREEN VAGINAL DISCHARGE WITH A STRONG ODOR. SMALL, RED, ULCERATIONS OF THE VAGINAL WALL ARE ALSO SEEN. A WET MOUNT PREPARATION DEMONSTRATES MOTILE, FLAGELLATED PROTOZOA. WHAT IS THE CAUSAL AGENT?
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SERIAL CLINICAL CASE 2/5
A 26-YEAR-OLD WOMAN COMPLAINS TO HER PHYSICIAN OF DISCOMFORT DURING INTERCOURSE. PELVIC EXAMINATION DEMONSTRATES A FROTHY, YELLOW-GREEN VAGINAL DISCHARGE WITH A STRONG ODOR. SMALL, RED, ULCERATIONS OF THE VAGINAL WALL ARE ALSO SEEN. A WET MOUNT PREPARATION DEMONSTRATES MOTILE, FLAGELLATED PROTOZOA.

MOST CASES OF INFECTION WITH THIS ORGANISM ARE ACQUIRED BY WHICH OF THE FOLLOWING ROUTES?
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SERIAL CLINICAL CASE 3/5
A 26-YEAR-OLD WOMAN COMPLAINS TO HER PHYSICIAN OF DISCOMFORT DURING INTERCOURSE. PELVIC EXAMINATION DEMONSTRATES A FROTHY, YELLOW-GREEN VAGINAL DISCHARGE WITH A STRONG ODOR. SMALL, RED, ULCERATIONS OF THE VAGINAL WALL ARE ALSO SEEN. A WET MOUNT PREPARATION DEMONSTRATES MOTILE, FLAGELLATED PROTOZOA.

WHICH OF THE FOLLOWING MEDICATIONS IS MOST OFTEN USED TO TREAT THIS WOMAN’S CONDITION?
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SERIAL CLINICAL CASE 4/5
A 26-YEAR-OLD WOMAN COMPLAINS TO HER PHYSICIAN OF DISCOMFORT DURING INTERCOURSE. PELVIC EXAMINATION DEMONSTRATES A FROTHY, YELLOW-GREEN VAGINAL DISCHARGE WITH A STRONG ODOR. SMALL, RED, ULCERATIONS OF THE VAGINAL WALL ARE ALSO SEEN. A WET MOUNT PREPARATION DEMONSTRATES MOTILE, FLAGELLATED PROTOZOA.

IF THIS WOMAN HAD BEEN PREGNANT AND HAD NOT BEEN TREATED, SHE AND/OR HER BABY WOULD BE AT MOST SIGNIFICANTLY INCREASED RISK OF WHICH OF THE FOLLOWING?
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SERIAL CLINICAL CASE 5/5
A 26-YEAR-OLD WOMAN COMPLAINS TO HER PHYSICIAN OF DISCOMFORT DURING INTERCOURSE. PELVIC EXAMINATION DEMONSTRATES A FROTHY, YELLOW-GREEN VAGINAL DISCHARGE WITH A STRONG ODOR. SMALL, RED, ULCERATIONS OF THE VAGINAL WALL ARE ALSO SEEN. A WET MOUNT PREPARATION DEMONSTRATES MOTILE, FLAGELLATED PROTOZOA.

A WOMAN DIAGNOSED WITH THIS DISEASE SHOULD ALSO BE EVALUATED FOR WHICH OF THE FOLLOWING?

END OF CLINICAL CASE.
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SERIAL CLINICAL CASE 1/4
A 32-YEAR-OLD WOMAN COMES TO THE PHYSICIAN BECAUSE OF A VAGINAL DISCHARGE AND ITCHING AND DISCOMFORT IN HER GENITAL AREA. SHE STATES THAT THE SYMPTOMS STARTED ABOUT 3 DAYS AGO. SINCE THAT TIME, SHE HAS NOTED A PROGRESSIVE WORSENING.
SHE ALSO COMPLAINS OF DYSPAREUNIA AND DYSURIA. SHE HAS NO SIGNIFICANT PAST MEDICAL HISTORY. HER PAST SURGICAL HISTORY IS SIGNIFICANT FOR AN APPENDECTOMY AT THE AGE OF 17. SHE TAKES NO MEDICATIONS AND IS ALLERGIC TO PENICILLIN.
PELVIC EXAMINATION DEMONSTRATES MARKED ERYTHEMA AND MILD EDEMA OF THE VULVA WITH A FEW EXCORIATIONS OF THE VULVA. A VAGINAL DISCHARGE IS SEEN, WHICH IS WHITE, THICK, AND CLUMPY WITH A COTTAGE CHEESE APPEARANCE. THE VAGINAL PH IS 4.5. A SAMPLE OF THE VAGINAL DISCHARGE IS PLACED ON A SLIDE AND TREATED WITH 10% POTASSIUM HYDROXIDE. MICROSCOPY REVEALS LYSIS OF NORMAL CELLULAR ELEMENTS WITH BRANCHING PSEUDOHYPHAE AND BUDS.
WHICH OF THE FOLLOWING IS THE MOST LIKELY DIAGNOSIS?
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SERIAL CLINICAL CASE 2/4
A 32-YEAR-OLD WOMAN COMES TO THE PHYSICIAN BECAUSE OF A VAGINAL DISCHARGE AND ITCHING AND DISCOMFORT IN HER GENITAL AREA. SHE STATES THAT THE SYMPTOMS STARTED ABOUT 3 DAYS AGO. SINCE THAT TIME, SHE HAS NOTED A PROGRESSIVE WORSENING.
SHE ALSO COMPLAINS OF DYSPAREUNIA AND DYSURIA. SHE HAS NO SIGNIFICANT PAST MEDICAL HISTORY. HER PAST SURGICAL HISTORY IS SIGNIFICANT FOR AN APPENDECTOMY AT THE AGE OF 17. SHE TAKES NO MEDICATIONS AND IS ALLERGIC TO PENICILLIN.
PELVIC EXAMINATION DEMONSTRATES MARKED ERYTHEMA AND MILD EDEMA OF THE VULVA WITH A FEW EXCORIATIONS OF THE VULVA. A VAGINAL DISCHARGE IS SEEN, WHICH IS WHITE, THICK, AND CLUMPY WITH A COTTAGE CHEESE APPEARANCE. THE VAGINAL PH IS 4.5. A SAMPLE OF THE VAGINAL DISCHARGE IS PLACED ON A SLIDE AND TREATED WITH 10% POTASSIUM HYDROXIDE. MICROSCOPY REVEALS LYSIS OF NORMAL CELLULAR ELEMENTS WITH BRANCHING PSEUDOHYPHAE AND BUDS.

WHICH OF THE FOLLOWING IS THE MOST LIKELY PATHOGEN?
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SERIAL CLINICAL CASE  3/4
A 32-YEAR-OLD WOMAN COMES TO THE PHYSICIAN BECAUSE OF A VAGINAL DISCHARGE AND ITCHING AND DISCOMFORT IN HER GENITAL AREA. SHE STATES THAT THE SYMPTOMS STARTED ABOUT 3 DAYS AGO. SINCE THAT TIME, SHE HAS NOTED A PROGRESSIVE WORSENING.
SHE ALSO COMPLAINS OF DYSPAREUNIA AND DYSURIA. SHE HAS NO SIGNIFICANT PAST MEDICAL HISTORY. HER PAST SURGICAL HISTORY IS SIGNIFICANT FOR AN APPENDECTOMY AT THE AGE OF 17. SHE TAKES NO MEDICATIONS AND IS ALLERGIC TO PENICILLIN.
PELVIC EXAMINATION DEMONSTRATES MARKED ERYTHEMA AND MILD EDEMA OF THE VULVA WITH A FEW EXCORIATIONS OF THE VULVA. A VAGINAL DISCHARGE IS SEEN, WHICH IS WHITE, THICK, AND CLUMPY WITH A COTTAGE CHEESE APPEARANCE. THE VAGINAL PH IS 4.5. A SAMPLE OF THE VAGINAL DISCHARGE IS PLACED ON A SLIDE AND TREATED WITH 10% POTASSIUM HYDROXIDE. MICROSCOPY REVEALS LYSIS OF NORMAL CELLULAR ELEMENTS WITH BRANCHING PSEUDOHYPHAE AND BUDS.

THIS PATIENT IS STARTED ON MICONAZOLE. THIS MEDICATION WORKS VIA WHICH OF THE FOLLOWING MECHANISMS?
SELECCIONE UNA:

SERIAL CLINICAL CASE 4/4
A 32-YEAR-OLD WOMAN COMES TO THE PHYSICIAN BECAUSE OF A VAGINAL DISCHARGE AND ITCHING AND DISCOMFORT IN HER GENITAL AREA. SHE STATES THAT THE SYMPTOMS STARTED ABOUT 3 DAYS AGO. SINCE THAT TIME, SHE HAS NOTED A PROGRESSIVE WORSENING.
SHE ALSO COMPLAINS OF DYSPAREUNIA AND DYSURIA. SHE HAS NO SIGNIFICANT PAST MEDICAL HISTORY. HER PAST SURGICAL HISTORY IS SIGNIFICANT FOR AN APPENDECTOMY AT THE AGE OF 17. SHE TAKES NO MEDICATIONS AND IS ALLERGIC TO PENICILLIN.
PELVIC EXAMINATION DEMONSTRATES MARKED ERYTHEMA AND MILD EDEMA OF THE VULVA WITH A FEW EXCORIATIONS OF THE VULVA. A VAGINAL DISCHARGE IS SEEN, WHICH IS WHITE, THICK, AND CLUMPY WITH A COTTAGE CHEESE APPEARANCE. THE VAGINAL PH IS 4.5. A SAMPLE OF THE VAGINAL DISCHARGE IS PLACED ON A SLIDE AND TREATED WITH 10% POTASSIUM HYDROXIDE. MICROSCOPY REVEALS LYSIS OF NORMAL CELLULAR ELEMENTS WITH BRANCHING PSEUDOHYPHAE AND BUDS.

THE KOH WET PREPARATION IS FALSELY NEGATIVE IN 25% OF CASES OF VULVOVAGINAL CANDIDIASIS. WHICH OF THE FOLLOWING REPRESENTS THE SENSITIVITY OF THE KOH WET PREPARATION FOR IDENTIFYING CANDIDIASIS?
END OF CLINICAL CASE.
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SERIAL CLINICAL CASE 1/3
A 70-YEAR-OLD MAN IS SEEN BY HIS FAMILY PRACTICE PHYSICIAN DURING A ROUTINE OFFICE VISIT. THE MAN COMPLAINS OF NOT FEELING WELL FOR THE LAST THREE MONTHS. FURTHER QUESTIONING REVEALS THAT THE PATIENT HAS A CHRONIC, UNPRODUCTIVE COUGH THAT HE ATTRIBUTES TO AN OLD SMOKING HISTORY. PHYSICAL EXAMINATION IS NOTABLE FOR A 7 KG WEIGHT LOSS SINCE THE LAST OFFICE VISIT THREE MONTHS PREVIOUSLY. A MULTINODULAR INFILTRATE IS SEEN IN THE LUNG FIELD BEHIND AND ABOVE THE RIGHT CLAVICLE.
THE PATIENT IS INJECTED INTRADERMALLY WITH PPD. 3 DAYS AFTER THE INJECTION, THERE IS A 13-MM DIAMETER AREA OF INDURATION AT THE INJECTION SITE. THIS REACTION IS AN EXAMPLE OF WHICH OF THE FOLLOWING TYPES OF IMMUNE RESPONSE?
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SERIAL CLINICAL CASE 1/2
A 60-YEAR-OLD MAN PRESENTS TO THE EMERGENCY DEPARTMENT COMPLAINING OF SHORTNESS OF BREATH, COUGH, AND COPIOUS SPUTUM PRODUCTION. HE STATES THAT HE HAS BEEN COUGHING FOR YEARS, AND HAS HAD INCREASED SPUTUM PRODUCTION FOR SEVERAL MONTHS EACH YEAR. ON EXAMINATION, HE IS OBESE, AFEBRILE, CYANOTIC, AND IN ACUTE DISTRESS. COARSE RALES ARE AUSCULTATED BILATERALLY AT THE LUNG BASES. HE SMOKES TWO PACKS OF CIGARETTES A DAY AND HAS A SEVENTY-FIVE PACK-YEAR SMOKING HISTORY. A CHEST X-RAY FILM APPEARS NORMAL, EXCEPT FOR SLIGHTLY ENLARGED LUNG FIELDS
WHICH OF THE FOLLOWING IS THE MOST LIKELY DIAGNOSIS?
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SERIAL CLINICAL CASE 1/3
A 72-YEAR-OLD WOMAN PRESENTS TO THE EMERGENCY DEPARTMENT WITH COUGH, FEVER, AND SHORTNESS OF BREATH. THE WOMAN LIVES ALONE AT HOME, BUT SPENDS PART OF EACH DAY SHOPPING AND RIDING PUBLIC BUSES. APPROXIMATELY 4 DAYS PREVIOUSLY SHE HAD DEVELOPED AN UPPER RESPIRATORY INFECTION.
APPROXIMATELY 2 DAYS AGO, SHE ABRUPTLY BECAME MUCH MORE ILL, AND HER SYMPTOMS STARTED WORSENING, BEGINNING WITH A SINGLE, LONG, SHAKING CHILL. SINCE THAT TIME, SHE HAS HAD FEVER, PAIN WITH BREATHING, COUGH, AND DYSPNEA. SHE DECIDED TO COME TO THE EMERGENCY DEPARTMENT WHEN HER TEMPERATURE AT HOME WAS 39.5. IN THE EMERGENCY DEPARTMENT, HER TEMPERATURE IS 39.9 C, BLOOD PRESSURE IS 90/50 MM HG, PULSE IS 120/MIN, AND RESPIRATIONS ARE 30/MIN. NO BREATH SOUNDS ARE HEARD OVER HER LOWER LEFT LUNG FIELD, BUT THEY CAN BE HEARD AT OTHER SITES. A CHEST X-RAY FILM WOULD BE MOST LIKELY TO DEMONSTRATE WHICH OF THE FOLLOWING:
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SERIAL CLINIC CASE 1/2

A 59-YEAR-OLD WOMAN WITH A HISTORY OF RHEUMATOID ARTHRITIS, WHICH NEEDS CHRONIC TREATMENT WITH NON-STEROIDAL ANTI-INFLAMMATORY DRUGS AND CORTICOSTEROIDS AS PROTECTION, IS PRESENTLY IN THE INTENSIVE CARE UNIT FOR ACUTE MYOCARDIAL INFARCTION IN ANTERIOR WALL WHICH OCCURRED 3 DAYS AGO. 10 MINUTES AGO, PATIENT STARTED FEELING INTENSE PRECORDIAL CHEST PAIN, IRRITABILITY, AGITATION, NAUSEA, DYSPNEA, AND VOMITTED IN TWO OCCASIONS. PHYSICAL EXAMINATION SHOWS: BP 90/50, FC 95 BEATS/MIN, DIAPHORESIS, CARDIAC SOUNDS WITH GALLOP RHYTHM.

THE FOLLOWING DIAGNOSIS IS ESTABLISHED:

SERIAL CLINIC CASE 2/2

A 59-YEAR-OLD WOMAN WITH A HISTORY OF RHEUMATOID ARTHRITIS, WHICH NEEDS CHRONIC TREATMENT WITH NON-STEROIDAL ANTI-INFLAMMATORY DRUGS AND CORTICOSTEROIDS AS PROTECTION, IS PRESENTLY IN THE INTENSIVE CARE UNIT FOR ACUTE MYOCARDIAL INFARCTION IN ANTERIOR WALL WHICH OCCURRED 3 DAYS AGO. 10 MINUTES AGO, PATIENT STARTED FEELING INTENSE PRECORDIAL CHEST PAIN, IRRITABILITY, AGITATION, NAUSEA, DYSPNEA, AND VOMITTED IN TWO OCCASIONS. PHYSICAL EXAMINATION SHOWS: BP 90/50, FC 95 BEATS/MIN, DIAPHORESIS, CARDIAC SOUNDS WITH GALLOP RHYTHM.

THE INDICATED THERAPEUTIC INTERVENTION FOR THIS PATIENT IS:

50-YEAR-OLD MALE, CHRONIC SMOKER, DIABETIC AND HYPERTENSIVE MULTITHREADED. WITH HISTORY OF GASTROESOPHAGEAL REFLUX. HE INDICATES PAIN IN EPIGASTRIUM AT DAWN OR IN THE LATE POSTPRANDIUM WHICH IMPROVES WITH THE INTAKE OF FOOD, AS WELL AS ABDOMINAL DISTENSION. THE ESOPHAGOGASTRODUODENAL SERIES SHOWS ULCERATIVE NICHE IN GASTRIC ANTRUM.

IT IS THE MOST FREQUENT CLINICAL HISTORY IN PATIENTS WITH THIS PATHOLOGY:

PREGNANT WOMAN WITH 39 WEEKS OF PREGNANCY, PREVIOUS CESAREAN SECTION 1 YEAR AGO, SHE STARTED LABOR AT HOME, PRESENTS RUPTURE OF MEMBRANES 1 HR. AGO, GOES TO EMERGENCY ROOM WITH REGULAR UTERINE ACTIVITY, ADECUATE FETAL CONDITIONS AND CERVICAL DILATION OF 4 CM WITH PALPABLE CEPHALIC PRESENTATION. AFTER HER ENTRY SHE PRESENTS SEVERE ABDOMINAL PAIN AND OF UTERINE CONTRACTIONS. THE EXAMINATION SHOWS AMORPHOUS ABDOMEN, IT IS NOT POSSIBLE TO LISTEN THE FETAL FOCUS. AT TOUCH IT IS PERCEIVED THE LOSS OF THE PRESENTATION AND INTENSE TRASVAGINAL BLEEDING. AN EMERGENCY LAPAROTOMY IS DONE, WHICH SHOWS A LOSS OF CONTINUITY IN THE UTERINE TISSUE IN THE FIRST 8 LOWER CENTIMETERS WITH PARTIAL PRESENCE OF THE FETUS AND PLACENTA IN THE ABDOMINAL CAVITY.

IT CORRESPONDS TO THE TYPE OR RUPTURE ACCORDING WITH THE CLINIC CASE

A 60-YEAR-OLD MAN GOES TO THE EMERGENCY ROOM BECAUSE OF PROGRESSIVE DYSPNEA AND TACHYCARDIA. FAMILY MEMBERS REPORT A HISTORY OF MYOCARDIAL INFARCTION A YEAR AGO WITHOUT ANY FOLLOW-UP AFTER BEING DISCHARGED FROM THE HOSPITAL. 2 WEEKS AGO PATIENT STARTED PRESENTING DYSPNEA ON MODERATE EXERTION, WEIGHT GAIN WITHOUT AN APPARENT CAUSE, AND EDEMA. PHYSICAL EXAMINATION SHOWS: BP 130/90. FC 120/MIN, CONSCIOUS, DYSPNEIC, PALE SKIN, DRY ORAL MUCOSA, PROTO-SYSTOLIC MURMUR IN AORTICA AREA AND ++ EDEMA IN LOWER LIMBS. COMPLEMENTARY EXAMS SHOW: EJECTION FRACTION OF 40%, MAXIMAL OXYGEN UPTAKE OF 20ML/KG/MIN, NA 130 MEQ/L, K 4 MEQ/L, B-TYPE NATRIURETIC PEPTIDE 470PG/ML.

THE FOLLOWING EXAM RESULT IS RELATED TO A BAD PROGNOSTIC FOR THE PATIENT:

A 42-YEAR-OLD MAN IS TAKEN TO THE EMERGENCY ROOM BY HIS FAMILY MEMBERS WHO REPORT A 2-DAY HISTORY OF PROGRESSIVE AND INTERMITTENT LOSS OF ALERTNESS. THEY ALSO REPORT ABNORMAL CORPORAL MOVEMENTS WHILE IN THEIR WAY TO THE HOSPITAL. PATIENT ALSO HAS A HISTORY OF BACK PAIN FROM 5 DAYS AGO WHICH WAS TREATED WITH COMPLEX B AND DEXAMETHASONE. PHYSICAL EXAMINATION SHOWS: BP 80/50, TEMPERATURE 38°C, PALPEBRAL OPENING, MOTION TO STIMULUS PAINFUL WITHDRAWAL, NO VERBAL RESPONSE, SUNKEN EYEBALLS, DRY ORAL MUCOSA AND HYPERREFLEXIA. LAB EXAMS SHOW THE FOLLOWING RESULTS: HB 17.3, HTC 53, LEUKOCYTES 8500, GLUCOSE 631, CHOLESTEROL 200, TRIGLYCERIDES 100. GENERAL URINALYSIS SHOWS: CLOUDY URINE, UNCOUNTABLE LEUKOCYTES AND BLOOD TRACES.

THE MOST PROBABLE CLINCAL DIAGNOSIS IS:

A 42-YEAR-OLD MAN IS TAKEN TO THE EMERGENCY ROOM BY HIS FAMILY MEMBERS WHO REPORT A 2-DAY HISTORY OF PROGRESSIVE AND INTERMITTENT LOSS OF ALERTNESS. THEY ALSO REPORT ABNORMAL CORPORAL MOVEMENTS WHILE IN THEIR WAY TO THE HOSPITAL. PATIENT ALSO HAS A HISTORY OF BACK PAIN FROM 5 DAYS AGO WHICH WAS TREATED WITH COMPLEX B AND DEXAMETHASONE. PHYSICAL EXAMINATION SHOWS: BP 80/50, TEMPERATURE 38°C, PALPEBRAL OPENING, MOTION TO STIMULUS PAINFUL WITHDRAWAL, NO VERBAL RESPONSE, SUNKEN EYEBALLS, DRY ORAL MUCOSA AND HYPERREFLEXIA. LAB EXAMS SHOW THE FOLLOWING RESULTS: HB 17.3, HTC 53, LEUKOCYTES 8500, GLUCOSE 631, CHOLESTEROL 200, TRIGLYCERIDES 100. GENERAL URINALYSIS SHOWS: CLOUDY URINE, UNCOUNTABLE LEUKOCYTES AND BLOOD TRACES.

THE TREATMENT THAT THE PATIENT SHOULD RECEIVE IS WITH:

35-YEAR-OLD WOMAN SEMIPROFESSIONAL VOLLEYBALL PLAYER. IS SUSPECTED OF INJECTING DRUG USE. WITH HISTORY OF ARTHROSCOPY ON LEFT KNEE 6 MONTHS AGO. STARTS HER CONDITION 48 HRS AGO WITH DYSPHAGIA, COUGHING, EVENING PURULENT EXPECTORACION, ARTHRALGIA AND MYALGIA. SYMPTOMS ADDED 8 HOURS AGO: FEVER OF 39-40°C, CHILLS, REJECTION OF FOOD, PAIN ON LEFT KNEE THAT INCREASES WITH MOVEMENT AND INABILITY TO WALK. EXPLORATION SHOWS ERYTHEMATOUS HYPERTROPHIC TONSILS WITH PURULENT OOZE, NON-COMPROMISED CARDIOPULMONAR, HYPEREMIC LEFT KNEE, EDEMATOUS AND ERYTHEMATOUS, PAINFUL TO PALPATION, ARCS OF MOTION DECREASED

IT CORRESPONDS TO THE IMAGE STUDY INDICATED AT THIS TIME:

35-YEAR-OLD WOMAN SEMIPROFESSIONAL VOLLEYBALL PLAYER. IS SUSPECTED OF INJECTING DRUG USE. WITH HISTORY OF ARTHROSCOPY ON LEFT KNEE 6 MONTHS AGO. STARTS HER CONDITION 48 HRS AGO WITH DYSPHAGIA, COUGHING, EVENING PURULENT EXPECTORACION, ARTHRALGIA AND MYALGIA. SYMPTOMS ADDED 8 HOURS AGO: FEVER OF 39-40°C, CHILLS, REJECTION OF FOOD, PAIN ON LEFT KNEE THAT INCREASES WITH MOVEMENT AND INABILITY TO WALK. EXPLORATION SHOWS ERYTHEMATOUS HYPERTROPHIC TONSILS WITH PURULENT OOZE, NON-COMPROMISED CARDIOPULMONAR, HYPEREMIC LEFT KNEE, EDEMATOUS AND ERYTHEMATOUS, PAINFUL TO PALPATION, ARCS OF MOTION DECREASED

IT CORRESPONDS TO THE TREATMENT OF CHOICE IN THIS CASE:

A 29-YEAR-OLD WOMAN WITH A HISTORY OF BRONCHIAL ASTHMA, SULFA ALLERGIES AND ARTERIAL HYPERTENSION FOUR YEARS AGO. GOES FOR A ROUTINE CHECKUP. PATIENT REPORTS TINNITUS, PHOSPHENE, CEPHALALGIA AND PALPITATIONS. PHYSICAL EXAMINATION SHOWS BP 160/100, FC 96/MIN, RF 18/MIN, RHYTHMIC HEART SOUNDS. PATIENT IS ADMITTED FOR OBSERVATION AND BLOOD PRESSURE CONTROL

THE FOLLOWING DRUG WOULD NOT BE ADVISED FOR THIS PATIENT:

A 29-YEAR-OLD WOMAN WITH A HISTORY OF BRONCHIAL ASTHMA, SULFA ALLERGIES AND ARTERIAL HYPERTENSION FOUR YEARS AGO. GOES FOR A ROUTINE CHECKUP. PATIENT REPORTS TINNITUS, PHOSPHENE, CEPHALALGIA AND PALPITATIONS. PHYSICAL EXAMINATION SHOWS BP 160/100, FC 96/MIN, RF 18/MIN, RHYTHMIC HEART SOUNDS. PATIENT IS ADMITTED FOR OBSERVATION AND BLOOD PRESSURE CONTROL

CORRESPONDS TO THE MECHANISM OF ACTION OF THE DRUG WHICH IS NOT ADVISED FOR THE PATIENT:

30 YEAR-OLD FEMALE WITH GESTATIONAL DIABETES WHO COMES TO REMOVAL OF STITCHES BY CAESAREAN SECTION 5 DAYS AGO. SHE HAS HISTORY OF ANEMIA AND URINARY TRACT INFECTIONS OF RECURRENCE DURING PREGNANCY. INDICATES ABDOMINAL PAIN, CHILLS AND INTENSE HEADACHE. PHYSICAL EXAMINATION SHOWS TEMPERATURE OF 38.5°C, BLOOD PRESSURE 80/60, HEART RATE 105 X´, UTERINE FUNDUS IS PALPATED ABOVE THE PUBIS SYMPHYSIS, FOUL HEMATOLOGIC LOCHIA.

RISK FACTOR MOSTLY ASSOCIATED TO THE PRESENT PATHOLOGY:

30 YEAR-OLD FEMALE WITH GESTATIONAL DIABETES WHO COMES TO REMOVAL OF STITCHES BY CAESAREAN SECTION 5 DAYS AGO. SHE HAS HISTORY OF ANEMIA AND URINARY TRACT INFECTIONS OF RECURRENCE DURING PREGNANCY. INDICATES ABDOMINAL PAIN, CHILLS AND INTENSE HEADACHE. PHYSICAL EXAMINATION SHOWS TEMPERATURE OF 38.5°C, BLOOD PRESSURE 80/60, HEART RATE 105 X´, UTERINE FUNDUS IS PALPATED ABOVE THE PUBIS SYMPHYSIS, FOUL HEMATOLOGIC LOCHIA

IT IS A MARKER OF SEVERITY AND PROGRESSION OF THE DISEASE:

30 YEAR-OLD FEMALE WITH GESTATIONAL DIABETES WHO COMES TO REMOVAL OF STITCHES BY CAESAREAN SECTION 5 DAYS AGO. SHE HAS HISTORY OF ANEMIA AND URINARY TRACT INFECTIONS OF RECURRENCE DURING PREGNANCY. INDICATES ABDOMINAL PAIN, CHILLS AND INTENSE HEADACHE. PHYSICAL EXAMINATION SHOWS TEMPERATURE OF 38.5°C, BLOOD PRESSURE 80/60, HEART RATE 105 X´, UTERINE FUNDUS IS PALPATED ABOVE THE PUBIS SYMPHYSIS, FOUL HEMATOLOGIC LOCHIA.

IT CORRESPONDS TO THE GOAL OF GLYCAEMIA THAT THE PATIENT SHOULD HAVE:

22-YEAR-OLD WOMAN SEXUALLY ACTIVE FROM THE AGE OF 13, MULTIPLE SEXUAL PARTNERS. ANTECEDENT OF PURULENT LEUCORRHOEA WITH 2 WEEKS OF EVOLUTION. GOES TO CONSULTATION BY PRESENCE OF DYSURIA, PYURIA, INTENSE DISABLING SUPRAPUBIC PAIN. VAGINAL EXAMINATION OBSERVES ABSCESS IN THE BARTOLINI GLAND, ERYTHEMATOSUS ANTERIOR CERVIX WITH EDEMA. THE VAGINAL SECRETION IS SAMPLED, THE SMEAR REPORTS GRAM-NEGATIVE INTRACELLULAR DIPLOCOCCI.

THE MOST PROBABLE ETIOLOGY CORRESPONDS TO:

22-YEAR-OLD WOMAN SEXUALLY ACTIVE FROM THE AGE OF 13, MULTIPLE SEXUAL PARTNERS. ANTECEDENT OF PURULENT LEUCORRHOEA WITH 2 WEEKS OF EVOLUTION. GOES TO CONSULTATION BY PRESENCE OF DYSURIA, PYURIA, INTENSE DISABLING SUPRAPUBIC PAIN. VAGINAL EXAMINATION OBSERVES ABSCESS IN THE BARTOLINI GLAND, ERYTHEMATOSUS ANTERIOR CERVIX WITH EDEMA. THE VAGINAL SECRETION IS SAMPLED, THE SMEAR REPORTS GRAM-NEGATIVE INTRACELLULAR DIPLOCOCCI.

THE INDICATED TREATMENT IN THIS CASE IS WITH:

35 YEAR OLD FEMALE WITH POOR DIABETIC CONTROL TREATED WITH NPH INSULIN AND METFORMIN, WITH A HISTORY OF IRREGULAR MENSTRUAL CYCLES, NO PREVIOUS PREGNANCY. GOES TO CONSULTATION DUE TO 12 WEEKS AMENORRHEA AND SUSPICION OF PREGNANCY. EXPLORATION SHOWS BMI 30.5, PALE SKIN, GLOBE-LIKE ABDOMEN BY ABUNDANT PANNICULUS ADIPOSUS, UTERINE GROWTH IS NOT PALPATED NOR THE FETAL CARDIAC FOCUS IS LISTENED. IMMUNE PREGNANCY TEST POSITIVE, HEMOGLOBIN A1C 7.5, CAPILLARY BLOOD SUGAR IN FASTING 138 MG/DL.

IS THE CONGENITAL MALFORMATION THAT WITH MORE FREQUENCY COULD PRESENT THE FETUS OF THIS PATIENT :

35 YEAR OLD FEMALE WITH POOR DIABETIC CONTROL TREATED WITH NPH INSULIN AND METFORMIN, WITH A HISTORY OF IRREGULAR MENSTRUAL CYCLES, NO PREVIOUS PREGNANCY. GOES TO CONSULTATION DUE TO 12 WEEKS AMENORRHEA AND SUSPICION OF PREGNANCY. EXPLORATION SHOWS BMI 30.5, PALE SKIN, GLOBE-LIKE ABDOMEN BY ABUNDANT PANNICULUS ADIPOSUS, UTERINE GROWTH IS NOT PALPATED NOR THE FETAL CARDIAC FOCUS IS LISTENED. IMMUNE PREGNANCY TEST POSITIVE, HEMOGLOBIN A1C 7.5, CAPILLARY BLOOD SUGAR IN FASTING 138 MG/DL.

IT CORRESPONDS TO THE CATEGORY OF DRUG RISK OF NPH INSULIN DURING PREGNANCY:

FIRST PREGNANCY, 18 YEAR-OLD, GOES TO ANTENATAL CONSULTATION WITH PREGNANCY IN THE SECOND TRIMESTER. STARTS HER AILMENT 3 DAYS AGO WITH URINARY URGENCY AND DYSURIA. PHYSICAL EXPLORATION SHOWS BLOOD PRESSURE 110/60, HEART RATE 74X’, TEMPERATURE OF 36.6°C, GLOBE-LIKE ABDOMEN WITH PREGNANT UTERUS OF 21 CM, PAIN AT PALPATION IN HYPOGASTRIUM. URINE TEST PH7, PYURIA, HEMOGLOBIN +, LEUKOCYTES ++.

IT IS THE MOST LIKELY CLINICAL DIAGNOSIS FOR THIS PATIENT:

FIRST PREGNANCY, 18 YEAR-OLD, GOES TO ANTENATAL CONSULTATION WITH PREGNANCY IN THE SECOND TRIMESTER. STARTS HER AILMENT 3 DAYS AGO WITH URINARY URGENCY AND DYSURIA. PHYSICAL EXPLORATION SHOWS BLOOD PRESSURE 110/60, HEART RATE 74X’, TEMPERATURE OF 36.6°C, GLOBE-LIKE ABDOMEN WITH PREGNANT UTERUS OF 21 CM, PAIN AT PALPATION IN HYPOGASTRIUM. URINE TEST PH7, PYURIA, HEMOGLOBIN +, LEUKOCYTES ++.

IT CORRESPONDS TO THE CAUSAL AGENT EXPECTED IN THIS CASE :