Case studies

“H.N., a 3-year-old normally healthy, immunized girl with a runny nose and mild cough for the last 3-4 days woke up in the middle of the night with severe shortness of breath. She had expiratory wheezing. She was taken to the emergency department with HR 130, RR 44, Sat 93% and temp 37C. On physical exam, she had tight end-expiratory wheezing, intercostal and supraclavicular accessory muscles of respiration to help her breathe. A chest X-ray revealed hyperluscent and over-inflated lungs. Blood testing revealed an arterial blood pH of 7.25.”
Critical Thinking Questions:

1. What other questions in the history would have been helpful in this diagnosis, and why?

2. What medications would be helpful in treating this patient? What do you think the plan of care will be for this patient, and why?

“E.J. is a 24-year-old teacher and avid mountain biker. She considers herself very healthy as she exercises regularly (5 day/week aerobic workouts; resistance training 3 sessions/week); follows a strict vegan diet (she stopped eating all meat and dairy products ~ 3 years ago d/t health and ethical reasons); doesn?t smoke and has no more than 1 glass of wine/meal ~ 4 times/week. She takes OCPs and a daily MVI. She presents to your clinic with ?no energy.?
Critical Thinking Question:”

What are the recommendations for this patient for a management plan, given the diagnosis?

“T.H., a 74-year-old woman with a history of rheumatic fever while in her twenties, presented to her primary care provider with complaints of increasing shortness of breath upon exertion. She also noted that the typical swelling she has had in her ankles for years has started to get worse over the past two months, making it especially difficult to get her shoes on toward the end of the day. In the past week, she has had a decreased appetite, some nausea and vomiting, and tenderness in the right upper quadrant of the abdomen.
On physical examination, Martha’s jugular veins were noticeably distended. Auscultation of the heart revealed a low-pitched, rumbling systolic murmur, heard best over the left upper sternal border. In addition, she had an extra “S3″ heart sound”.

Critical Thinking Questions:

1. Which term more accurately describes the stress placed upon T.H.?s heart ? increased preload or increased afterload ? and why?

2. How might T.H.?s body compensate for the above condition?

3. A chest X-ray reveals a cardiac silhouette that is normal in diameter. Does this rule out a possible problem with T.H.?s heart? Explain.



“A previously healthy 3-year-old boy presents to your office with fever and refusal to walk for 2 days. Exam of the lower extremities reveals no redness, warmth or swelling. Passive ROM of the rt hip is significantly decreased and painful. Parents deny any history of trauma.
Exam: VS T 39.5, P 120, R 18, BP 100/50, oxygen saturation 100% in RA. Wt 10th percentile, Ht 50th percentile.
Laboratory studies show WBC 20,000, 80% segs, 10% bands, 8% lymphs, 2% monos, Hct/Hgb 14/43, Platelet count 265,000. ESR 45. CRP 12. Serum glucose 95. UA SG 1.020, negative for blood. EKG normal sinus rhythm. Hip radiographs show widening of the acetabular space on the right.
UTD immunizations.
No recent Abx use.
No rashes, skin lesions.
No n/v/d. Decreased appetite today.
URI symptoms 2 weeks ago. Resolved.
Previously healthy without injury, travel, bites.
No congenital or birth problems”.

Critical Thinking Questions:

1. What other differentials might be concerning in this patient? What is the pathophysiologic basis of your answer?

2. How does the age of this patient help you narrow the final diagnosis?

“L.R. is a 43-year-old female with a history of mood swings that have become progressively more debilitating over the past several years. She is currently in an ?up? mood and feels she is doing fine. However, her husband says he is worried because she is spending a lot of money on various things and is not sleeping at night. Sometimes she won?t sleep all night, and she will have just a short nap in the afternoon. She is otherwise physically well and has no other significant past medical history”.

Critical Thinking Questions:

What medications might be considered as treatment for this patient, and why?


“B.B. is a 45-year-old gentleman who presents with symptoms of acute lower back pain following his lifting of a heavy load and presents with the following physical findings:

* He cannot straighten up
* Point tenderness over his lumbar spine
* Numbness over the left anterior thigh and leg, extending all the way to the medial aspect of his foot and great toe
* Motor testing finds some weakness in knee extension
* Diminished patellar reflex
* Positive straight leg raise on the left

Critical Thinking Questions:

1. What are the ?red flags? of back pain that must be considered in the management of any patient? Explain the pathophysiology of the ?red flags.? If this patient had any of them, how would it change the management plan?

2. What is cauda equina? How do you know if this patient has it?

3. What might cause a patient to be more susceptible to a vertebral fracture?