MEDICAL CASE 1

A 52-year old comes to your office for a routine physical examination. He is a

new patient to your practice. He has no phisycal medical history and takes no
medication regularly. His father died at the age of 74 of a heart attack. His
mother is alive at the age of 80. He has 2 younger siblings with no chronic
medical condition. He does not smoke cigarette, drink, alkohol, use any drug
recreational, and does not exercise. On eximination, his blood pressure is
127/82mm Hg, pulse is 80 beats/min, respiratory rate is 18 breaths/min, height is
67 inches, and weight is 190 lb. On careful phisycal examination, no
abnormalities are noted.

 What screening test(s) for cardiovascular diseases should be

recommended for this patient?
 What screening test(s) for cancer shold be recommended?
 What immunization(s) should be recommended

Language Centre of Malahayati University @ 2010

 MEDICAL CASE 2

A 52-year-old man present to your office for an accute visit because of coughing
and shortness of breath. He is well-known to because of multiple office visit in the
past few years for similiar reason. He has chronic “smoker’s caugh”, but reports
in the past 2 days his cough has increased, his sputum has changed from white
to green in color and he has had to increase the frequency with which he uses
his albuterol inhaler. He denies having fever, chest pain, peripheral edema, or
other symptoms. His medical history is significant for hypertensio, pheriperal
vascular disease, and 2 hospitalization pneumonia in the past 5 years. He has a
60-pack-history of smoking and continuous to smoke 2 packs of cigarretes a day.

On examination, he is in moderate respiratory distress. His teperature is 98.4 o F

degree, his blood pressure is 152/95 mm Hg, his pulse is 98 beats/ min, his
respiratory rate is 24 breaths/min, and he has an oxygen saturation of 94% on
room air. His lung is significant for diffuse expiratory wheezing and a prolonged
expiratory phase of respiration. There are no sign of cyanosis. The reminder of
his examination is normal. Chest x- ray done in your office shows an increased
anteroposterior (AP) diameter and flattened diaphragms, otherwise clear lung
fields.

 What the most likely cause of this patient dyspnea?

 What acute treatment(s) most appropriateat this time?
 What intevention would be most helpful to reduce the risk of future
exacerbation of this condition?

Language Centre of Malahayati University @ 2010

 MEDICAL CASE 3

A 45-year-old white male present to your office complaining of left knee pain that
started last night. He says the pain started suddenly after dinner and was severe
within the span of 3 hours. He denies any trauma, fever, systematic symptoms or
prior similiar episodes. He has history of hypertension for which he takes
hydrochlorothiazide (HTCZ). He admit to consuming a great amount of wine last
night with dinner.

On exam, his temperature is 98o F, his pulse is 90 beats/min, his respiration is 22

breaths/min, and his blood pressure is 129/88 mm Hg. Heart and lung
examinations are unremarkable. The patient is flex to the left knee, wincing in
pain at touch, passive range of motion. The knee is edematous, hot to touch, and
has erythema of the overlying skin. No crepitation or deformity is apparent. No
other joint is involved. Inguinal lymph nodes are not enlarged. Complete blood
count reveals a white blood cell count of 10,900 cells/mm 3 and otherwise normal.

 What is the next diagnostic step?

 What is the most likely diagnosis?
 What is the next step in the therapy?

Language Centre of Malahayati University @ 2010

 MEDICAL CASE 4

A 22-year-old woman who has never been pregnant before presents to you after
having a positive home pregnant test. She has no significant medical history.
After further questioning, she states that she is unsure of the date of her last
menstrual period. She denies recently had dental x-ray taken prior to discovering
she was pregnant any symptoms and is worried as she has not felt the baby
moves thus far. She is also concerned as she. Patient denies the use of any
drugs, alcohol, or tobacco. She inquires about when she can get an ultrasound
and a genetic test to rule out Down syndrome.

 When is an ultrasound indicated in parental care?

 What laboratory studies are routinely indicated at an initial prental visit?
 What is the risk to the pregnancy based on the radiation exposure that the
patient has encountered?
 When is the optimal for screening with a trisomy screen test?

Language Centre of Malahayati University @ 2010

 MEDICAL CASE 5

A 6-month-old male is brougth to your office by his mother for a routine well child
visit. His mother concerned that he is not saying “mama” by age 6 months. Your
patient is born to a full-term, uncomplicated pregnancy to a 23-year-old gravida1
para1 mother. He was delivered by a spontaneous vaginal delivery and there
were no complications in the neonatal period. You have been following him since
his birth. He has had appropriate growth and development up to his age and up-
to-date on his routine immunizations. He had an upper respiratory infection at
age 5 months that was treated symptomatically. There is no family history of any
developmental, hearing or speech disorders. He has been fed since birth with an
iron –fortified infant formula. Cereal and other baby food were added starting at
the age 4 months. He lives with both parents, neither of whom smoke
ciggarettes.

On examination, he is a vigorous infant who is at the 50th percent of length and

weight and 75 th percentile for head circumferences. His physical examination is
normal. On developmental examination, he is seen to sit to a short period of time
without support, reach out with one hand for your eximining light, pick up a
Cheerio with a raking grasp put it in his mouth, and is noted to babble frequently.

 What immunizations should be recommended at this visit?

 What age should an infant say “mama” and “dada”?
 The child’s mother asks when can place him in front-racing car seat. What
is your recommendation?

Language Centre of Malahayati University @ 2010

 MEDICAL CASE 6

A 35-year-old female with history of asthma presents to your office with

symptoms of nasal itching, sneezing, and rhinorrhea. She states she feels this
most day but her symptoms are worse in spring and fall. She has had difficulty
sleeping because she is always congested. She said she has taken
diphenyldramine (Benadry) with no relief. She does not smoke cigarettes and
does not have exposure to passive but she does have 2 cats at home. On
examination, she appears tired but is in no respiratory distress. Her vital signs
are temperature, 98.8oF; blood pressure, 128/84mm Hg; pulse, 88 beats/min;
respiratory rate, 18 breath/min. The mucosa of her nasal turbinates appear
swollen (boggy) and have a pale, bluish-gray color. Thin and watery secretions
are seen on ear examination. There is no cervical lymphadenopathy noted and
her lungs are clear.

 What is most likely diagnosis?

 What is your next step?
 What are important considerations and potential complication of
management?

Language Centre of Malahayati University @ 2010

 MEDICAL CASE 7

A 55-year-old male comes to your office for follow-up of a chronic cough. He also
complains of shortness of breath with activity. He reports that this has been
getting worse over time. As you are interviewing the patient, you note that he
smells of cigarette smoke. Upon further questioning, he reports smoking 1 pack
of cigarette perday for the last 35 years and denies ever being advised to quit.
On examination, he has no respiratory distress at rest. His vital vital signs are
normal, and he has no abvious sign of cyanosis. His pulmonary examination is
notable for reduced air movement and faint expiratory wheezing auscultation.

 What would you recommend for this patients?

 What interventions are available to aid with smoking cessation?

Language Centre of Malahayati University @ 2010

 MEDICAL CASE 8

A 16-year-old female presents to your office with complaint of greenish vaginal

discharge for the past 2 months and the recent onset of abdominal pain. She
reports that her last period was about 2.5 months ago. She is sexually active with
two partners and has never use condom or any contraception with either. On
physical examination, she is not febrile with normal blood pressure and pulse.
She has greenish discharge from the cervix with friability and cervisitis. There is
no cervical motion tenderness. Her urine pregnancy test is positive. A cervical
sample is positive for Chlamydia and negative for gonorrhea. Her rapid plasma
reagin (RPR) is nonreactive and HIV test is negative.The patient is treated with
proper antibiotics and counselled for save sex practices. You also inform the
patient regarding her risk for HIV conversation, even though today’s test was
negative. The patient asks if you are going to tell her mother that she is pregnant
and has this infection. You inform the patient that because of patient
confidentiality ethical consideration you will not disclose this information to her
mother without her consent. She tells you that she does not want her mother to
know and she does not want her boy friend to know that she is infected.

 What should you do?

 What should you tell the patient?
 What are the ethical considerations?
 What are the guidelines for reporting communicable diseases?

Language Centre of Malahayati University @ 2010

 MEDICAL CASE 9

A 60-year-old African-American female presented to the emergency room

complaining of worsening shortness of breath and pelpitation for about 1 week.
She feels dizzy ‘on and off’ for the past year with ‘dizziness’ is assosiated with
weakness that has been worsening for the past month. She feels so tired to even
to walk to her back yard and water her flower bed that she used to do ‘all the
time’. She has been so dyspenic walking up the stairs at her home that she
moved down stairs to the quest room about a week ago. Review of system is
negative which she frequently takes apirin or ibuprofen, otherwise the review of
the system is negative. She has no significant medical history and has not been
to a doctor for several years. She had a normal well woman examination and
screening colonoscopy about 5 years ago. She occasionally has an alcoholic
drink and denies tobacco and drug use. She is married and a retired house
keeper. On examination, her blood pressure is 150/85 mm Hg ; her pulse is 98/
min; her respiratory rate 20 breaths/min/ her temperature is 98.7 o F; and her
oxygen saturation is 99% on room air. Significant findings on examination include
conjunctival pallor, mild tenderness with deep palpation in the epigastric and left
upper quadran (LUQ) region of the abdomen with normal bowel sounds, no
organomely but a positif stool guaiac test. The reminder of the examination,
including respiratory, cardiovascular, and nervous system, normal.

 What is the most likely diagnosis?

 What is your next diagnosis step?
 Waht is the next step in therapy?

Language Centre of Malahayati University @ 2010

 MEDICAL CASE 10

A 40-year-old man presents to your clinic complaining of having 10 episode of

watery, nonbloody diarrhea that started last nigh. He vomited twice last night but
has been able to tolarate liquids today. He has had intermittent abdominal
crampsas well. He reports muscle aches, weakness, headache, and low grade
temperature. He is here with his daughter, who started with the same symptom
this morning. On questening, he stats that he has no significant medical history,
no surgery, and does not take any medications, He does not smoke cigarretes,
drink alcohol, use any illicit drugs, has never had blood transfusion. He and his
family returned to United States yesterday, following a week-long vacation in
Mexico.

On examination, he is not in an acute distress. His blood pressure is 110/60 mm

Hg, his pulse is 98/min, his respiratory breath is 16 breaths/min, and his
temperature is 99.1o F. His mucous membranes are dry. His bowel sound is
hyperactive and his abdoment is mildly tender throughout, but there is no
rebound tenderness and no guarding. A rectal examination is normal and his
stool is guaiac negative. The reminder of his examination is unremarkable.

 What is the most likely diagnosis?

 What would you do next?
 What are potential complication?

Language Centre of Malahayati University @ 2010

 MEDICAL CASE 11

50-year-old Caucasian female, new to your practice, present for an “annual

physical examination”. She reports that she is generally healthy, feels well and
has no specific complaints. She has a history of having “partial hysterectomy”, by
which she means that her uterus and cervix were removed and her ovaries were
left in place. The surgery was performed because of fibroids. She has had a pap
smear since the age of 18, all of which have been normal. She has no other
significant medical or surgical history. She has had annual mammograms since
the age of 40, all of which have been normal. She takes multivitamin pills daily
but no other medications. Her family history is significant for breast cancer that
was diagnosed in her maternal grandmother at the age of 72. The patient is
married, monogamous, does not smoke cigarettes or drink alcohol. She tries to
avoid dairy products because of “lactose intolerance”.She walks 3 miles 4-times
a week for exercise. Her physical examination is normal.

 For this patient, how often should a pap smear be performed for cervical
cancer screening?
 What could you recomend to reduce the risk of developing osteoporosis?
 What is the recommended interval for screening mammography?

Language Centre of Malahayati University @ 2010

 MEDICAL CASE 12

A 25-year-old male presents to your office on a Monday morning with an ankle

pain. He was playing his usual Suturday afternoon basketball game when he
injured his right ankel. He says that he jumped for a rebound and landed on
another player’s foot. His right ankle “rolled over”, he fell to the floor, and his
ankle started to hurt. He did not hear or feel a pop. He was able to stand and
walk with a limp, but was unable to continue playing. His ankle swelled over the
next day in spite of rest, icing, and elevation. He suffered no other injury from that
fall. On his examination, he is a well-appearing man with normal vital signs. The
lateral aspect of the right ankle is swollen. The right ankle has normal dorsiflexion
and plantar flexion and there is no focal tenderness to palpation of the fibula,
malleoli, or foot. No ligamentous laxity is noted on testing. He can bear weight
with minimal pain. There is normal sensation and capillary refill in the food. The
reminder of his examination is normal.

 What is the most likely diagnosis of this injury?

 What further diagnostic testing is needed at this time?
 What is the most appropriate therapy?

Language Centre of Malahayati University @ 2010

 MEDICAL CASE 13

A 45-year-old white female presents to your office concerned about a “mole” on

her face. She says that it has been present for year but her husband has been
urging her to have it checked. She denies of any pain, itching or bleeding from
the site. She has no history of skin cancer in her family. She is an accountant by
occupation.

On examination, the patient is normotensive, afebrile, and appears slightly

younger than her stated age. A skin examination reveals a nontender, symmetric,
4-mm papule that is uniformly reddish-brown in color. The lesion is well
circumscribed, the surrounding skin is normal in appearance. There are no other
lesions in the area.

 What is the most likely diagnosis?

 What features are reassuring of a benign condition?
 What is your next step?

Language Centre of Malahayati University @ 2010

 MEDICAL CASE 14

A 40-year-old male with no past medical history presents to the clinic to establish
care. He reports that he had a prior urinalysis that revealed blood as an
accidental finding. The urinalysist was done as a standard screening test by his
former employe. He denies ever seeing any blood in his urine and denies any
voiding difficulties, dysuria, sexual dysfunction, or any history or risk factors of
sexually transmitted desease. His review of system is other wise negative. He
has smoked a half-pack of cigarrete per day in past ten years and exercise by
jogging 15 minutes and light weight training daily. On examination, his vital signs
are normal and the entire physical examinations are unremarkable. A complete
blood count (C BC) and a chemistry panel (electrolites, blood urea nitrogen, and
creatinin) are normal. The result of a urinalysis done in your office are; specific
gravity, 1.015; pH 5.5;leukocyte esterase, negative;nitries, negative; white blood
cell count (WBC),0;red blood cell count (RBC),4-5 per-high-powerfield(HPF).

 What is your diagnosis?

 How would you approach this patient?
 What is the work-up and plan for this patient?
 What are the concerns and how would you councel the patient?

Language Centre of Malahayati University @ 2010

 MEDICAL CASE 15

A 27-year-old patient presents to your office complaining progressive

nervousness, fatique, palpitation, and the recent development of a resting hand
tremor. She also states that she is having difficulty consentrating at work and
she has been irritable with her coworkers. The patient is also notes that she
developed persistent rash over the shins which is not improved with the use of
topical steroid creams. All of her sympyoms have come on gradually, over the
past few months and continue to get worse. Review of systems also reveals
unintentional weight loss of about 10 pounds, insomnia, and amenorrhea for the
past 2 months (the patient’s menstrual cycle are usually quite regular). The
patient’s past medical history is unremarkable and she takes no oral medications.
She is currently not sexually active, does not drink alcohol, smoke or use any
illict drugs. On examination, she is afebrile. Her pulse varies from 70-110 beats
per minute. She appears restless and anxious. Her skin is warm and moist. Her
eyes show evidence of exophthalmos and lid retraction bilaterally, although
funduscopic examination is normal. Neck examination reveals symetric thyroid
enlargement, without any discrete palpable masses. Cardiac examination reveals
an irregular rhythm. Her lungs are clear to auscultation. Extremety examination
reveals an erythematos, thicken rash on both shins. Neurologic examination is
normal except for a fine resting tremor in her arms when she atempts to hold out
her outstretched arms. Initial lab test include a negative pregnancy test and
undetectable level of thyroid-stimulating hormone (TSH).

 What is the most likely diagnosis?

 What imaging study is most appropriate at this time?
 What is the definitif nonsurgical treatment of this condition?

Language Centre of Malahayati University @ 2010

 MEDICAL CASES 16

A 25-year-old gravida2, para woman at 36 weeks estimated gestational age

presents to the labor and delivery triage unit stating that her “bag of water has
broken.” She reports having had a large gush of clear fluid followed by a constant
leakage of of fluid from her vagina. She subsequently started having uterine
contractions approximately every 4 minutes. She has had an uncomplicated
prenatal course with good prenatal care since 8 weeks’ gestation. Her prenatal
records are avilable for review in the triage unit. Her first pregnancy resulted in
the full-term delivery of a 7 lb 8 oz, healthy boy.

In the triage unit, she is placed on an external fetal monitor. Her blood pressure
is 110/70mm Hg; her pulse is 90 beats/min, and her temperature is 98.7 o

Her general examination is norma. Her abdominal is gravid, with fundemental

height of 38 cm. The fetus has a cephalic presentation Leopold maneuvers and
an estimated fetal weight of 8 lb.

 What sign and test could confirm the present of rupture of membranes?
 On the fetal monitoring strips shown (Fig. 16-1), what is the approximate
baseline fetal heart care?
 Her prenatal records reveal that she had positive group B streptococcus
(GBS) vaginal culture at 36 weeks’gestation. What theraphy should be
instituted at this time?

Language Centre of Malahayati University @ 2010