230 BIOL SPRING 2011 CLINICAL CASE STUDIES (50 POINTS) DR. TELLES Imagine you are following a Nurse Practitioner as part of your clinical experience in nursing school. Before you enter the examining room the Nurse Practitioner pulls the chart off the door and hands it to you. You enter the room and greet the patient. What is your tentative diagnosis? Each case study is worth 2 points. Use a scantron to answer the following questions. Clinical Case 1 A 62-year old diabetic man presents himself in the emergency room with a swollen left leg with areas of blanching and blue mottling. A "foul odor" is coming from a dressed wound. The physicians remove the dressing and a brownish fluid is seeping from a wounded area. The fluid contains what appear to be small bits of the tissue. No pus appears to be present. The wound has a strong "rotten" odor. Five days earlier, while at his work as a farmer, he caught the leg in his manure spreader, sustaining a deep, crushing, grossly dirty injury. His wife cleaned the wound as well as she could with soap and water, dressed it with clean gauze, and wrapped it tightly with an elastic bandage to stop the bleeding. The second day they redressed the wound and applied triple antibiotic ointment. The patient treated his pain with ibuprofen (Advil). He reported the pain was not very bad for the first 72 hours. In the past 24 hours, the leg swelled and the mottling began to appear. A foul odor and severe pain accompanied the swelling. His wife convinced him to come to the emergency room even though they did not have medical insurance. What organism is most likely to be responsible for these symptoms and findings? a. b. c. d. Clinical case 2 A 3 month old baby, Jarret Fox, was admitted into the ER for dehydration. According to his mother, the baby had stopped eating four days ago. Jarret was about 5% dehydrated and was much floppier than usual. He seemed passive and expressionless and lay as limp as a rag doll in his hospital crib. An emergency electromyogram (a test of Jarret's muscle and nerve function) revealed abnormal nerve responses. His breathing has become labored and when a blood-gas analysis revealed signs of respiratory failure, he was transferred to the ICU where he was placed on a ventilator. The mother assured the doctor that the baby was exclusively breast-fed. On further inquiry, the doctor finds out that his little sister had offered him a spoonful of oatmeal topped with natural honey straight from the hive on the day that he stopped eating. What was the diagnosis? Clostridium tetani E.coli 0157:H7 Clostridium perfringens Bacillus anthracis Dr. C. Telles Page 1 a. Tuberculosis b. Botulism c. Tetanus d. Scalet fever Clinical Case 3 A 58-year old lawyer is presented in the emergency room with a headache, irritability, generalized muscle pain and uncontrollable back spasms. He has become very restless and worried because he has had the back spasms all through his court case that afternoon and they became extremely painful. In his history, the lawyer states that he has a very busy practice. He is on medication for high blood pressure and has mild asthma. He injured himself about 10 days earlier, puncturing his left arm with a nail from an old barn he is tearing. The wound has produced moderate quantities of pus, but he has been keeping it clean. The wound was sampled for microscopic examination and culture. The back appears to have very tight contractions and spasms. The patient is in obvious agonizing pain. What type of infection do you believe he has? a. b. c. d. Clinical Case 4 Streptococcus pyogenes Clostridium tetani Pseudomonas aeruginosa Clostridium botulinum A 68-year old patient with Alzheimer disease was brought to the emergency room by the staff of a local nursing home. He presented as lethargic with a sallow complexion. He had an admission temperature of 102.4F and a respiratory rate of 33/minute. During respiration, the right side of his chest moved better than the left. He showed dense consolidation of the lower lobe of the left lung on physical exam. A sputum sample revealed blood and a greenish color. A chest x-ray showed tight consolidation of the left lung with evidence of formation of cavities in the lung tissue from cytotoxic damage. The patient complained of chills in the exam room, combined with his fever. A smear of his sputum demonstrated no acid-fast bacteria. What type of infection do you believe he has? a. Staphylococcus aureus b. Streptococcus pyogenes c. Mycobacterium tuberculosis d. Streptococcus penumoniae Clinical Case 5 A 24-year old female automotive technician presents herself at the nurse practitioner's office. She complains of fever and of pain in her left hand. On physical examination, the patient had a deep wound on her left palm that was oozing pus. She had purplish, red streaks running up her left arm. She had enlarged lymph nodes at the elbow and under her arm. The patient's skin was warm and dry. In her history, the patient had punctured her left palm with a sharp metal from the Dr. C. Telles Page 2 undercarriage of a "real cherry" 1977 Malibu about a week earlier. She said the wound had bled for a few minutes and she thought that she had washed it "real good" with soap and water. She had covered the wound with a large "band-aid" and gone back to work. She developed a fever about three days later. For the past couple of days, she "did not feel so good" and had vomiting and diarrhea. What type of infection do you believe she has in this hand? a. b. c. d. Clinical Case 6 Streptococcus pyogenes Staphylococcus aureus Clostridium botulinum Pseudomonas aeruginosa A male college student is presented to the emergency room at an outside hospital with a pounding headache, vomiting, and a stiff neck with pain running up his back. On admission, his temperature was 101F. The young man appeared to have trouble hearing during the nurse's interview and also seemed to have trouble concentrating. The history revealed that the young man was a wrestler for the local high school team. He had felt as though he were getting a cold the past few days, since his last meet in Hicksville. He did not smoke or drink, but he attended a party two days earlier thrown by his girlfriend and the other cheerleaders to celebrate his victory in the sectionals. He had been holding his weight at 162 pounds for the season, so he ate little and did not drink on the day of the meet s (today is the day of the meet). On the physical exam, the nurse practioner observed several areas of purplish spots on the skin of the back, thigh, and arm. The boy thought those were from wrestling. Blood cultures were drawn and a Gram stain revealed Gram-negative cocci in pairs. What type of infection do you believe he has? a. Staphylococcus aureus b. Neisseria meningiditis c. Mycobacterium tuberculosis d. Streptococcus pneumoniae Clinical Case 7 A 22-year old woman presents at the walk-in health clinic with slight fever (38.5C), a complaint of frequent urination, burning on urination, vaginal discharge and a small lesion on the labia. The woman reported that she was moderately sexually active and had three sexual partners in the past six months. Her last sexual contacts were about 7 days earlier. She had developed mild symptoms about 5 days earlier, beginning with a discharge from the vagina. She began having pain on urination about 3 days earlier. Urine analysis revealed a pH of 8.2, some white cells and a few red blood cells. There was protein in the urine. A smear of the vaginal secretion showed a number of Gram-negative cocci. What was the diagnosis? a. Syphilis b. HIV infection c. Gonorrhea d. Shingles Dr. C. Telles Page 3 Clinical Case 8 A 27-year old female presented at the walking clinic of her local physician on August 15. On physical exam, the patient had a fever of 38.5C. She appeared fatigued, had tender joints, and complained of a headache, a stiff neck and a backache. The nurse practitioner noticed a circular "rash" about 5 inches in diameter, with a bright red leading edge and a dim center in the form of a "bull's eye". The nurse practitioner noted an irregular heart beat. The patient complained of lack of ability to concentrate. The patient gave the following history: She is a graduate student in the wildlife program at the university in town. She was in the field for three weeks in Wisconsin during the months of May and June. She tracks small mammals in the field and studies their behavior. It had been a warm, wet spring and she complained of a large number of biting flies, mosquitoes and ticks in the area. She felt well until about 2 weeks after returning to her home. Since that time, many of her symptoms had progressed. She finally found that she could take it no more. What is your best diagnosis of this case? a. Epidemic Typhus b. Rocky mountain spotted fever c. Lyme disease d. Tularemia Clinical Case 9 A 24-year old, female graduate student in biology presented with exhaustion, weakness and a low grade fever. She was pale and showed poor ability to concentrate. Her history revealed that she had gradually become increasingly tired and weakened over the past two months. She had experienced low-grade fevers over the past month and felt she would need to drop out of her graduate program if she did not get this under control. On examination, she had a temperature of 100F. She complained of a sore throat and had enlarged cervical lymph nodes. A blood test reveals an elevated number of damaged Blymphocytes. What was the diagnosis? a. Yellow fever b. Cold sores c. Mononucleosis d. Shingles Clinical Case 10 At the Mount Union hospital, a 5-year old male child in general good health and physical condition was presented at the Saturday walk-in clinic by his mother. He was brought in because he had a fever, was cranky and had complained of a sore throat for about 24 hours. On physical examination by the attending nurse practitioner, the patient had a fever of 39.3C, and he had considerable swelling and drainage of the pharynx and in the conjunctivae. His tonsils were enlarged and coated with a white patchy exudate. He had a red throat and swollen anterior cervical lymph nodes. His ears were clear. His chest sounded clear and he had no additional remarkable findings on routine examination. Blood samples reveal cocci in chains. What type of infection do you believe he has? Dr. C. Telles Page 4 a. Streptococcus pyogenes b. Clostridium tetani c. d. Pseudomonas aeruginosa Clostirdium botulism Clinical Case 11 A 35-year old Native-American male presents himself in the clinic with a complaint of recurrent low-grade fevers, sweating, weakness, muscle pains and a loss of about 10% of his body weight over a 4 month period. The worsening weakness and muscle pain prompted the visit. The patient reports that he has been working on a bison slaughter line owned by his tribe, and blood and tissue juices often splash in his face or contaminate minor hand and arm injuries. He likes to hunt and fish. He is married and has two children. He eats fairly well, but he has not been as hungry lately. He had rheumatic fever as a child and was in a fairly serious car accident three years earlier, resulting in a leg broken in three places. He feels he was physically fit prior to the past 4 months. He likes to play basketball and softball. He has had all the usual childhood immunizations, but does not see the doctor often. On physical examination, the patient has a temperature of 101F. He has mildly swollen lymph nodes in the neck and under the arms. He has blood pressure of 136/86, and a normal heart rate without a heart murmur. There is no evidence of acute respiratory or gastrointestinal infection. What would be your diagnosis for this patient? a. b. c. d. e. Anthrax Dengue fever Brucellosis Malaria Tularemia Clinical Case 12 A missionary couple, living in West Africa, bring their 4-year old son to the office of their physician on the second day of a visit home to Minnesota. The boy had a mild episode of diarrhea about seven days earlier and would not eat. He seemed to recover, but the mother noticed that the boy was having trouble walking the previous night and had seemed to have trouble dressing himself and walking that day. On examination, the patient had no significant fever (98.9) and normal bowel sounds. His chest, ears and eyes were clear. He had no rebound tenderness in the abdomen. The physician noted that the child had poor muscular reflexes in his arms and legs. The child also was a bit lethargic and seemed confused. The family lives in an isolated village in Africa. The mother opposes vaccinations on personal grounds, so the child has only had the initial series of DPT shots and no other typical vaccines. The village where they live has many problems with parasites and insect borne fevers (including Dengue). Urine, stool and blood samples were collected for analysis. This disease is most likely: Dr. C. Telles Page 5 a. b. c. d. an intestinal infection or parasite. a respiratory infection or parasite. a neurological infection or parasite. a urinary tract infection or parasite. Clinical Case 13 A lethargic 22-month old female was presented by her mother to the emergency room at 2:15am on a Sunday. The child had a history of a runny nose, hoarse cough and low-grade fever (~99F) for the past 48 hours. The mother was concerned about the forced and noisy breathing of the child. The pediatrician examined the child and found cloudy eyes and mild inflammation of the ears, but no overt signs of bacterial infection (no significant changes in the eardrums). The throat of the child was red and coated with mucus. The larynx was swollen and raw. The physician performed a rapid Strep test and found it was negative. Throat swabs were taken for culture. The physician placed the child in a room with a warm vaporizer for about 30 minutes. This dramatically improved the breathing of the child. Is this a bacterial or viral infection? What was the diagnosis? a. Bacterial b. Viral Clinical Case 14 A 20-year old female presents in her nurse practioner's office with genital itching and sharp, severe pain on the labia. She complains of three previous episodes of pain over the past 6 months, each of which were followed by the appearance of red sores which crusted and healed without a scar. On examination the nurse practioner observes a cluster of small red blisters localized in the area of the worst pain. No significant discharge was observed from the vagina. The patient's urine was clear and yellow. Urinalysis revealed normal specific gravity, no sugar, no protein, no white blood cells or red blood cells and no bacteria. The patient's temperature was 36.5C. The patient history reveals that she is unmarried. The young lady states that she has had 5 sexual partners over the past year and that her episodes have become progressively more severe. Given this person's history, what was the diagnosis? a. Hepatitis C b. Cervical cancer c. Shingles d. Liver cirrhosis Dr. C. Telles Page 6 Clinical Case 15 A 5 year old male child has a fever, headache, and malaise followed by small, teardrop shaped fluid-filled vesicles; the vesicles appear in successions of clusters; eventually the vesicles crust and fall off without leaving scars. What was the diagnosis? a. Smallpox b. Measles c. Rubella d. Chickenpox Clinical Case 16 A 35-year old accountant presented to his physician with a steady burning pain just right of the mid-line of the abdominal region in an area from 1 to 4 inches above the "belly button." The pain usually followed meals by about 1-3 hours. He had several episodes of vomiting, which included frank blood. On physical examination, the patient had no fever. He appeared generally well. He showed slight rebound tenderness in the upper abdomen. An occult blood test revealed the presence of blood. What organism is most likely to be responsible for these symptoms and findings? a. b. c. d. Bacillus cereus Helicobacter pylori Clostridium botulinum Samonella typhimurium Clinical Case 17 A 5 year old girl has a cough, running nose, watery red eyes and a characteristic pink-red rash that breaks out at the hairline which then covers the face and spreads to the body trunk. The rash is said to "stain", changing color from red to dark brown, before disappearing. What was the diagnosis? a. Smallpox b. Parainfluenza c. Severe acute respiratory syndrome d. Measles Clinical Case 18 A patient is brought into the ER in a coma. Upon inspection, he has evidence of many new tattoos as well as yellowing of the skin and eyes. What was the diagnosis? a. Hepatitis A b. Hepatitis B c. Mononucleosis d. Yellow fever Dr. C. Telles Page 7 Clinical Case 19 The patient is a young child who is experiencing a violent cough; a high-pitched sound accompanies inspiration; the windpipe appears blocked and the child is exhausted from the coughing and fever. What was the diagnosis? a. b. c. d. e. Diphteria Mumps Pertusis Cholera Tetanus Clinical Case 20 A patient is brought into the clinic. Her skin is wrinkled and cold; her eyes are gray and she complains of having muscular cramps in her arms and legs and rice water stools. A liter of water is lost per hour. Gram negative curved rods are found in a stool sample. What was the diagnosis? a. b. c. d. e. Botulism Staphylococcal food poisoning Cholera Gonorrhea Chicken-pox Clinical Case 21 Acid-fast bacilli appear in the patient's sputum; cough is deep and occasionally contains blood; patient lives in the ghetto and is malnourished. What was the diagnosis? a. b. c. d. Pneumonia Tuberculosis Syphilis Typhoid fever Clinical Case 22 A young child is brought into the clinic. The skin over the salivary glands is taut and shiny, and the area is painful when touched. The swelling is obvious in the salivary gland area on both sides of the face. What was the diagnosis? a. Shingles b. Rubella c. Mumps d. Smallpox Dr. C. Telles Page 8 Clinical Case 23 A patient is brought into the clinic with the initial symptoms of fever, headache, vomiting and backache. As the disease progresses, bleeding of the gums occurs and jaundice may also occur. Blood is also detected in vomit and feces. What was the diagnosis? a. Hepatitis A b. Hepatitis B c. Mononucleosis d. Yellow fever Clinical Case 24 A 40 year old woman was admitted into the ER with fever, chills, and a dry cough with little sputum. Epidemiologists isolated the pathogen in the cooling system of the air conditioning unit. Name the pathogen that causes this disease. a. b. c. d. e. Streptococcus pyogenes Bordetella pertusis Steptococcus pneumoniae Legionella pneumophila Neisseria meningiditis Clinical Case 25 In 1996, a medical student at the University of Maryland was assigned a case for a seminar on "underdetermined diagnosis in difficult cases." His patient was a gentleman who lived in the mid1800s and was a well-known poet and animal lover. The man was taken to a hospital with delirium and tremors. He was confused, combative, and he refused to drink any water or any liquid. He lived on Oct. 7th, 1849. When told the man's name, the student thought "Nevermore!" What was his diagnosis? a. Parainfluenza b. Yellow fever c. Small pox d. Rabies e. Shingles Can you guess who the patient was? Write the answer on the back of the scantron in the name field (2 bonus points) Dr. C. Telles Page 9