Course 1, Case 1
Revision 2010
Case 1-1E: An 18-year-old woman with mild fever, abdominal pain and dysuria
Current illness: Two days she got fever up to 38 °C without chills, general malaise, dysuria - burning at urination, lower abdominal pain, passing small portions of urine but frequently, the urine seems dark.
Personal history: No severe illness before, only common colds, 3 times tonsillitis, treated with antibiotics. Occasional cervical spine complaints. No operation, no injury. No regular medication except contraceptive pills. Menstruation from age 12, regular period. No known allergy.
Family history: Mother 43y healthy, father 45y had got nephrolithiasis, underwent lithotomy. One brother is healthy.
Social history: Lives with parents and brother. Student of high school.
Epidemiological history: One week on a camping trip, returned 2 days ago.
Physical examination (only significant or pathological findings are listed):
Patient conscious, well orientated, with no exanthem. T 38 °C; BP 120/70; pulse 90; tongue white and dry. Painful palpation of the lower abdomen, no resistance. Liver a spleen not palpable. Tapottement bilaterally negative. Meningeal signs: neck stiffness +1 cm, limited left and right rotation; Lassegue negative, spine sign negative.
Laboratory results:
ESR 28/45
Blood count: leukocytes 12000/μl, differential blood count with 70% neutrophils, 5% bands, 20% lymphocytes, 5% monocytes.
Serum: urea, creatinine, Na, K, Cl, liver tests - all within normal limits, CRP 61 mg/l. Urinalysis: protein +++, blood ++, bilirubin 0, urine sediment: leukocytes >5 per high-power field, erythrocytes >5 per high-power field, casts 0.
Questions:
1. What kind of infection is concerned?
2. Comment the values of inflammatory parameters. Is the disease rather viral or bacterial?
3. What is the most likely etiological agent?
4. What test can detect the etiological agent?
5. What are the basic therapeutic principles (symptomatic, causal treatment)?
6. How is affected more commonly – women or men – and why?
Pathophysiology: Factors predisposing to urinary tract infection.
Pathology: Classification and characteristics of urinary tract inflammatory diseases.
Course 1, Case 2
Revision 2010
Case 1-2E: A 43-year-old woman with fever, back pain and hypotension
Current illness: One week bothered with frequent urination and overall malaise, drank a herbal tea. Last 3 days she has got back pain, took ibuprofen, fever 38-38,5 °C, she thought it was flu. Yesterday she mentioned cloudy urine, vomited, therefore stopped drinking, in the evening fever raised up to 39,7°C with shivering. At night she collapsed when going to the toilet. The attending physician sent her to the hospital.
Personal history: Common childhood illnesses, appendectomy at 5 ys of age. Had got several biliary colics, at 30 ys of age cholecystectomy for lithiasis. Frequent low back pain, occasionally takes physiotherapy, once went to the spa. Previously frequent cystitis, she treated herself with herbal tea. No known alllergy. No regular medication except contraceptive pills.
Family history: Mother has got diabetes type I, father died in a car accident, brother has got defect of immunity. Two children healthy.
Gynecological history: menstruation from age 12, regular period, two labours, no previous gynecological illness.
Social history: Office worker, lives with the family.
Physical examination (only significant or pathological findings are listed): T 39,5 °C,
patient consciouss, slightly desorientated, cold acra, no icterus, no rash, normal skin turgor, BP 80/45, pulse 120/min weak, tongue white and dry, abdomen meteoristic, but soft with no pain, liver and spleen not enlarged; tapottement right-positive, left-negative; meningeal signs negative.
Laboratory results:
ESR 45/89
Blood count: leukocytes 24.000 /μl, erythrocytes 3.8 mil/μl, hemoglobin 101 g/l, thrombocytes 120.000/μl. Differential count: 83% neutrophils, 15% bands, granulation of neutrophils, 2% lymphocytes.
Serum: urea 10.4 mmol/l, creatinine 120 μmol/l, Na, K, Cl within normal limits, CRP 412 mg/l, glucose 10.4 mmol/l.
Urinalysis: protein +++, blood +++, glucose ++; urine sediment: leucocytes >5 per high-power field, erythrocytes 15-20, casts 5-10.
Questions:
- Which organ is affected by infection?
- How will you name the illness?
3. What is the likely pathogenesis of the illness?
4. What are the most common etiological agents?
5. Which clinical and laboratory signs speaks for sepsis?
6. Why is the patient hypotensive?
Pathophysiology: Pathophysiology of sepsis
Pathology: Interstitial renal disease
Course 1, Case 3
Revision 2010
Case 1-3E: A 6-year-old boy with fever, vomiting, diarrhoea, abdominal pain
Current illness: Yesterday the boy was refusing the food, at night he vomited, complained of abdominal pain, had got fever 38,6 °C, was given cold compresses and paracetamol. In the morning a diarhoea started, the stools were watery and greenish, boy continues vomiting and fever 39 °C. Refuses drinks and urinates a little. Attending pediatrician sent the boy to the surgical office for suspected appendicitis. The surgeon examined the child, carried out the basic blood tests, excluded an acute abdomen and sent the child to the infectious diseases dept.
Personal history: Perinatal data: child of 1st pregnancy, physiological, spontaneous in term delivery, head presentation, 3500g/51cm, not resuscitated, breast-fed 3months, hip joints with no dysplasia, postnatal development normal, vaccinated according schedule. At the age of five he had got chickenpox, three times otitis media with paracentesis. No injury, no operation. Since 4y of age has got pollinosis, allergy to pollen and dust, takes antihistamines seasonally. No regular medication. No other allergy. Fair social conditions, attends a grammar school.
Family history: Both parents are healthy.
Epidemiological history: Two days ago ate fried eggs.
Physical examination (only significant or pathological findings are listed): T 39 °C. Child consciouss but sleepy, pale, with sunken appearance of eyes, decreased skin turgor, tongue white but moist. Breathing alveolar, rate 28/min, P 108/min regular, no heart murmur. Pain on palpation in the right lower abdomen, where palpable soft resistance, borborygms on palpation, liver and spleen not enlarged, per rectum a thin green stool on the glove, palpation not painful. No meningeal signs.
Laboratory results:
ESR 34/56
Blood count: leukocytes 13.000/μl, differential blood count: 80% neutrophils, 10% bands, 10% lymphocytes.
Serum: urea 15.4 μmol/l, creatinine 120 μmol/l, Na 128 mmol/l, K 2,8 mmol/l, Cl 95 mmol/l, CRP 105 mg/l, glucose 3.5 mmol/l
Urinalysis: protein +, acetone ++, urine sediment: leuko15-20, ery 0, casts 0.
Questions:
- What will you name the disease (without specifying the etiology)?
- What are the most common etiological agents?
3. What test is applied for detection of the etiology?
- What can be the major threat for the patient?
5. What are the basic therapeutical principles?
6. How are ketones built?
Pathophysiology: Classification of diarhoea diseases with respect to causes and pathogenesis
Pathology: Intestinal inflammations (of infectious and non-infectious origin)
Course 1, Case 4
Revision 2010
Case 1-4E: A 6-year-old girl with fever, sore throat and rash
Current illness: Yesterday the girl was tired, complained of abdominal pain and sore throat, at night she got fever 39 oC, was given paracetamol 200mg. This morning fever again 38,5 oC, sore throat, mother noticed some rash on the abdomen.
Personal history: Perinatal data: child of 1st pregnancy, physiological, spontaneous in term delivery, head presentation, 3350g/50cm, no resuscitation, physiological icterus, breast-fed 4 months, hip joints with no dysplasia, vaccinated according schedule. No severe illness before, only common colds. No injury, operation - nasal adenotomy in 3ys of age. No regular medication. No known allergy. Fair social conditions, attends a kindergarten.
Family history: Father treated for high blood pressure, mother healthy, sister 3ys healthy.
Physical examination: T 38oC, girl conscious, responds adequatelly, complains of sore throat and mild headache. On the skin of the abdomen and axillae there is tiny maculopapular rash of red colour, confluent, slightly itching, with blanching under pressure or scratching. Face erythem with circumoral pallor, reddened throat and palatal tonsills, white tongue. Mild bilateral submandibular lymphadenopathy, slightly painful. Eupnoic, normal lung and heart sounds, HR 100/min, BP 90/60. Abdomen soft, no resistance, not tender, no hepatomegaly, no splenomegaly. Meningeal signs negative.
Questions:
1. What is the likely diagnosis?
2. What is the etiological agent?
3. In what material and what test can isolate the pathogen?
4. What other diseases can the pathogen cause?
5. What does cause the skin a mucosal signs in this disease?
6. What are the basic therapeutical principles?
Pathophysiology: Fever, its specific features in childhood. Principles of body temperature regulation and its disorders.
Pathology: Rheumatic fever
Course 1, Case 5
Revision 2010
Case 1-5E: A 19-year-old man with fever and sore throat
Current illness: About a week ago fever 38-38,5 °C started, general practitioner diagnosed acute tonsillitis and gave oral penicillin. There was no improvement with penicillin therapy. Last 2 days he can hardly swallow, lymph nodes on the neck are swollen, fever persists.
Personal history: In childhood chickenpox, several times otitis media with paracentesis, once pneumonia, no hospitalization. No operation, injury: forearm fracture at the age of 8, treated conservatively. No regular medication. No known alllergy.
Family history: Mother healthy, father was diagnosed with Bechterev´s disease, sister heatlhy.
Social history: Student, lives with the parents. Alcohol occasionally beer, no smoking, no drug abuse.
Physical examination: T 38,7 °C. Conscious, orientated. Normal hydration. Skin with no icterus, no rash, normal turgor. Nasal voice (rhinolalia), oral foetor, slight eyelids swelling, throat iflammed, tonsills reddened enlarged with yellowish pseudomembranes, petechiae on the palate, prominent submandibular lymphadenopathy – bilateral paquetts size 5x3 cm, painful. Eupnoic, normal lung and heart sounds, HR 90/min, reg., BP 120/70. Abdomen soft, well palpable, no pain, liver enlarged 2 cm, palpable spleen under left costal margin. signs negative.
Laboratory results:
ESR 18/30
Blood count: leukocytes 12.000/μl, differential count: 40% neutrophilic polymorphonuclears, 32% lymphocytes, 10% monocytes, 14 % atypical monocytes
Serum: CRP 17 mg/l, bilirubin 20 mmol/l, ALT 3.2 μkat/l, AST 1.9 μkat/l, ALP 1.6 μkat/l, GMT 1.7 μkat/l
Questions and tasks:
1. Is the disease rather of bacterial or viral origin?
2. Which of described data point on such origin?
3. What is the likely etiology?
4. Which organs belong to lymphatic system?
5. Does the liver belong to lymphatic system, too?
6. What types of cells are in the liver?
Patophysiology: Spleen: pathophysiological consequencies
Pathology: Inflammatory diseases of the upper respiratory tract
Course 1, Case 6
Revision 2010
Case 1-6E: A 16-year-old boy with fever and meningeal syndrome
Current illness: Three days of sore throat, with no fever, was training ice-hockey normally. Yesterday in the afternoon headache ant backache, fever 38,5 oC. At night he vomited, complained of severe headache, had fever 39 oC, small red spots occured on the skin of hands and legs. Since the morning is very sleepy. The emergency service took him to the hospital.
Personal history: No severe illness before, only common colds. Vaccinated according schedule. Operations: appendectomy in 10ys of age. Sport injuries – fracture of the left forearm, fractures of right hand fingers. No regular medication, sometimes vitamins. No known allergy.
Family history: Father was treated for duodenal ulcer, mother has got cervicobrachial syndrome, sister is healthy.
Social history: Lives with parents, student of the 1st year of high school. Active ice-hockey player training 4 times a week. No alcohol, no smoking, no drugs.
Epidemiological history: No known source of infection, no travel abroad in the last year.
Physical examination (only significant or pathological findings are listed):
T 39,2oC, patient somnolent, if wakened up can answer his name correctly, no more response. Neck stiffness 3 fingers, Lassegue + 60 degree bilat., other signs not examined. Small petechiae up to 3 mm on the skin of hands and legs. Skin turgor normal. Eyes – isocoric pupills, normal response to light. Throat slightly inflammed, dry tongue. No submandibular lymphadenopathy. Eupnoic, normal lung and heart sounds, HR 90/min, reg., BP 100/60, oxygen saturation 97%. No pathology on the abdomen.
Laboratory results:
ESR 20/40
Blood count: leukocytes 20.000/μl, erythrocytes 5.02 mil/μl,, hemoglobin 160 g/l, hematocrit 0.49, thrombocytes 120.000/μl
Serum: glucose 6.6 mmol/l, urea 7.0 mmol/l, creatinine 67 μmol/l, Na 140 mmol/l, K4.2 mmol/l, Cl 101 mmol/l, CRP 250 mg/l.
Coagulation: Quick 19.2 s, INR 1.5, APTT 67 s, R 2.1, D-dimers 2.000 (high), antitrombin III 60% (decreased)
CSF: turbid, polymorphonuclears 8.200/3μl, protein 4.5 g/l, glucose 0.8mmol/l, lactate 7mmol/l
Questions:
1. What type of meningitis is concerned?
2. What is the likely etiology?
3. What tests can detect the etiological agent?
4. What is the mechanism of fever?
5. Why is the patient uncouscious?
6. What kind of coagulation disorder is associated with the disease?
Pathology: Inflammation of the central nervous system
Pathophysiology: Acute adrenal failure
Course 1, Case 7
Revision 2010
Case 1-7E: A 60-year-old woman with fever and impaired consciousness
Current illness: Two weeks ago pain in the right ear started, with no fever, examined by general practitioner and given ear drops. The earache persisted. Last 2 days fever 38 oC and headache, vomited at night, since this morning she stays in bed, fever 39 oC, very sleepy, did not respond. The emergency service took her to the hospital.
Personal history: Common diseases in childhood. Ten years ago was treated for duodenal ulcer, after therapy without complaints. Three years ago diabetes type II and hypertension was diagnosed, put on diabetic diet and betablocker. Operations: 10ys ago hysterectomy for myoma. Regular medication: betaxolol (betablocker). No known alllergy.
Family history: Father with ischaemic heart disease and diabetes type II, died 70ys old due to acute myocardial infarction, mother died 80ys due to colonic carcinoma, 2 sons 30 and 34ys are healthy.
Social history: Lives with husband. Retired, school teacher before. Alcohol sporadically, no smoking, 2 coffees per day.
Epidemiological history: No known source of infection, no travel abroad in last year, a dog at home.
Physical examination:
T 39 oC, patient soporous, no response to speech, restless on painful stimuli, Glasgow Coma Scale score 8-9. Severe neck stiffness, Lassegue + 60 degrees bilat., other signs not examined. Skin with no icterus, no rash, no purpura, turgor normal. Eyes – isocoric pupillae, normal response to light. In the right ear dried purulent fluid. Throat not possible to examine fully, dry tongue mucosa. No palpable thyreopathy, carotid arteries palpable bilat. Normal lung and heart sounds, HR 80/min, reg., BP 145/100, sat O2 91%, snoring. No pathology on the abdomen.