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DR. J
CDT
Dr. Juan Carlo
s Díaz T
orre
CURSO DE INGLÉS
ENGLISH COURSE
Dr. Juan Carlos Díaz TorrePediatra Neonató[email protected]
(779) 100 - 40 - 26
1
DR. J
CDT
Dr. Juan Carlo
s Díaz T
orre
BRIEF CLINICAL CASES CASOS CLÍNICOS BREVES
(14)
Dr. Juan Carlos Díaz Torre
Pediatra Neonató[email protected](779) 100 - 40 - 26
2
DR. J
CDT
Dr. Juan Carlo
s Díaz T
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Case # 181
A 58-year-old male with a long history of hypertension and coronary artery disease comes to see you 3 weeks after an acute myocardial infarction. His hospitalization was punctuated by intermittent episodes of symptomatic cardiac arrhythmias and difficulties in controlling his blood pressure.
DR. J
CDT
Dr. Juan Carlo
s Díaz T
orre
4
Other than a history of a seizure disorder controlled by phenytoin (Dilantin), his past medical history is unremarkable. He complains of fatigue, headache, and lack of energy. After determining that his symptoms are not the result of medications or other systemic problems, you conclude that he is depressed and would benefit from an antidepressant. Appropriate medications include which of the following?:
DR. J
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Dr. Juan Carlo
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5
a) Nortriptyline (Pamelor)( ) True ( ) False
b) Paroxetine (Paxil) ( ) True ( ) False
c) Bupropion (Wellbutrin)( ) True ( ) False
d) Venlafaxine (Effexor) ( ) True ( ) False
DR. J
CDT
Dr. Juan Carlo
s Díaz T
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6
In order to maximize compliance, you tell him which of the following?
a) Side effects, such as nausea and sedation, are often transient and disappear after 1-2 weeks
( ) True ( ) False
DR. J
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Dr. Juan Carlo
s Díaz T
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b) It may take several weeks for improvement to be noted, and up
to 8 weeks for a full therapeutic response ( ) True ( ) False
c) Antidepressants are most effective when taken continuously
( ) True ( ) False
DR. J
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Dr. Juan Carlo
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d) Antidepressants usually can be discontinued 3-4 months after the
initial episode ( ) True ( )False
DR. J
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Dr. Juan Carlo
s Díaz T
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9
Four weeks later, the patient returns to your office. His depression is somewhat better, but he is complaining of erectile dysfunction and persistent daytime sleepiness.
Which of the following would be appropriate alternative drugs?
a) Nefazadone (Serzone) ( ) True ( )False
DR. J
CDT
Dr. Juan Carlo
s Díaz T
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b) Methylphenidate (Ritalin)( ) True ( ) False
c) Sertraline (Zoloft) ( ) True ( )False
d) Trazodone (Desyrel)( ) True ( ) False
DR. J
CDT
Dr. Juan Carlo
s Díaz T
orre
11
Case # 182
A 15-month-old African-American male is brought to your office by his mother, who gives a history of a cold that started about 10 days ago. Initially, he had a low-grade fever, a runny nose, and a slight cough. Now the fever has returned and he has become fussy. The nurse records a temperature of 39.0° C (102.2° F).
DR. J
CDT
Dr. Juan Carlo
s Díaz T
orre
12
You examine him and find a bulging, immobile tympanic membrane. Otherwise, he has normal physical findings. You review your records and note that he had an episode of acute otitis media only 6 months ago. It had resolved at a subsequent follow-up visit after treatment with amoxicillin. You make a presumptive diagnosis of a second episode of acute otitis media. You would now advise which of the following?:
DR. J
CDT
Dr. Juan Carlo
s Díaz T
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13
a) Myringotomy and culture( ) True ( ) False
b) Antibiotic therapy ( ) True ( ) False
c) Referral for pressure equalization tube placement
( ) True ( ) False
DR. J
CDT
Dr. Juan Carlo
s Díaz T
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d) Referral for adenoidectomy ( ) True ( ) False
e) Total and differential WBC count ( ) True ( )False
DR. J
CDT
Dr. Juan Carlo
s Díaz T
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15
Two weeks later the child is brought back to the office, and you note that the tympanic membranes are retracted and immobile. He is now afebrile and asymptomatic. You make a diagnosis of persistent middle ear effusion and advise the mother that there is persistent fluid behind the eardrum. Since this is his second episode of otitis, the next phase of treatment will require:
DR. J
CDT
Dr. Juan Carlo
s Díaz T
orre
16
a) Myringotomy and culture ( ) True ( ) False
b) Referral for pressure equalization tube placement
( ) True ( ) False
c) Referral for adenoidectomy ( ) True ( ) False
DR. J
CDT
Dr. Juan Carlo
s Díaz T
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d) Periodic observation until resolved( ) True ( ) False
DR. J
CDT
Dr. Juan Carlo
s Díaz T
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Case # 183
You have a patient who is going skiing for the first time. He comes to you for advice concerning the prevention of injuries and frostbite . After discussing musculoskeletal injuries, you would say that frostbite:
DR. J
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Dr. Juan Carlo
s Díaz T
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a) Is more profound when it occurs at high altitude than when it occurs at sea level, if all other factors are equal.
( ) True ( ) False
b) Can occur when the wind chill factor is below freezing even though the ambient temperature is above
freezing. ( )True ( ) False
DR. J
CDT
Dr. Juan Carlo
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c) Is less likely to occur if, just prior to skiing, a small amount of
alcohol is ingested for its vasodilating effect.
( ) True ( ) False
d) Can be self -treated if radiant heat is readily available. ( ) True ( ) False
DR. J
CDT
Dr. Juan Carlo
s Díaz T
orre
21
In spite of your good advice, the patient sustains a cold injury to the feet. He is taken to the clinic at the base of the mountain where the Doctor on duty observes the toes on both feet to be firm and cold to touch, with a pale, gray, bloodless appearance.
Appropriate treatment options would include:
DR. J
CDT
Dr. Juan Carlo
s Díaz T
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22
a) Wrapping the patient in a warm blanket.
( ) True ( ) False
b) Giving an alcoholic beverage as soon as practical. ( ) True ( )False
DR. J
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Dr. Juan Carlo
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c) Massaging the toes for a few minutes prior to instituting any other local therapy. ( ) True ( ) False
d) Rapidly rewarming the feet in circulating water at 90.0 -108.0° F.
( ) True ( )False
DR. J
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Dr. Juan Carlo
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e) Having the patient walk around as soon as rewarming is complete.
( ) True ( ) False
f) Telling the patient to apply pressure dressings at night prior to retiring.( ) True ( ) False
g) Surgically removing any part of the toes which is likely to become
devitalized.( ) True ( ) False
DR. J
CDT
Dr. Juan Carlo
s Díaz T
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25
Case # 184
A 24-year-old white female comes in for prenatal care for her third pregnancy. Both of her previous pregnancies resulted in preterm births at 30 weeks gestation. Her medical and obstetric history are otherwise negative .
DR. J
CDT
Dr. Juan Carlo
s Díaz T
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26
Which of the following measures has been demonstrated by randomized trial to reduce the likelihood of premature birth in this situation?:
a) Ritodrine (Yutopar), 40 mg/day ( ) True ( ) False
b) Magnesium chloride, 1 g twice daily ( ) True ( ) False
DR. J
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Dr. Juan Carlo
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c) Checking for cervical dilation beginning in the middle of the second trimester
( ) True ( ) False
d) Amniocentesis ( ) True ( ) False
DR. J
CDT
Dr. Juan Carlo
s Díaz T
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28
At 31 weeks, the patient presents with strong contractions occurring at 6 minute intervals; the contractions got progressively stronger while she was traveling to the hospital to be examined. Palpation confirms the strong contractions. Fundal height measurement and previous ultrasound determinations confirm the dates and size as appropriate for 31 weeks.
DR. J
CDT
Dr. Juan Carlo
s Díaz T
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29
Ultrasonography now indicates moderate polyhydramnios. The cervix is 50% effaced and 1 cm dilated.
Appropriate measures to delay labor would include which of the following?:
a) Intravenous alcohol. ( ) True ( ) False
DR. J
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Dr. Juan Carlo
s Díaz T
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b) Intravenous magnesium sulfate. ( ) True ( ) False
c) An angiotensin converting enzyme inhibitor. ( ) True ( ) False
d) A beta-adrenergic agent.( ) True ( ) False
DR. J
CDT
Dr. Juan Carlo
s Díaz T
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e) Fluid restriction. ( ) True ( ) False
f) Artificial rupture of the membranes.( ) True ( ) False
DR. J
CDT
Dr. Juan Carlo
s Díaz T
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32
Case # 185
A 2l-year-old African-American male comes to your office with intense pain in his right eye of several hours' duration and a feeling that there is "something scratchy in my eye." The pain began while the patient was at work, hammering on a piece of metal in the process of making wheel rims for automobiles.
DR. J
CDT
Dr. Juan Carlo
s Díaz T
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33
He does not recall any sensation of metal fragments striking his eye. He was not wearing safety glasses or contact lenses at the time. Your examination shows right conjunctival hyperemia with increased tearing and mild blepharospasm. Staining with fluorescein reveals an abrasion of the right cornea on the nasal side of the pupil, approximately 3 mm in size. The abrasion is slightly irregular in shape, and no foreign body is seen. Examination of the left eye is unremarkable.
DR. J
CDT
Dr. Juan Carlo
s Díaz T
orre
34
Further initial diagnostic studies should include:
a) Examination of the right eye under general anesthesia.
( ) True ( ) False
b) Digital pressure on the right eye to see if pain increases. ( ) True ( ) False
DR. J
CDT
Dr. Juan Carlo
s Díaz T
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35
c) A radiograph of the right eye. ( ) True ( ) False
The initial diagnostic evaluation reveals no abnormalities other than the obvious abrasion. Therapy at this time should include:
a) A topical anesthetic to be used every 3-4 hours.( ) True ( ) False
DR. J
CDT
Dr. Juan Carlo
s Díaz T
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36
b) A topical steroid in the right eye.( ) True ( ) False
c) A systemic antibiotic.( ) True ( ) False
DR. J
CDT
Dr. Juan Carlo
s Díaz T
orre
37
The patient returns in 48 hours and is still complaining of a " scratchy " sensation and pain with blinking . Examination of the eye reveals the corneal defect to be basically unchanged or just slightly smaller than at the initial examination.
At this time, proper management includes:
DR. J
CDT
Dr. Juan Carlo
s Díaz T
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38
a) A topical steroid for the next 48 hours and reexamination.( ) True ( ) False
b) A topical anesthetic for 48 hours and reexamination.
( ) True ( ) False
c) Referral to an ophthalmologist.( ) True ( )False
DR. J
CDT
Dr. Juan Carlo
s Díaz T
orre
39
Case # 186
A 45-year-old white businessman consults you after a blood bank refused his blood donation because of elevated blood pressure. During your evaluation, you find fluctuating levels of elevated blood pressure on several serial determinations.
DR. J
CDT
Dr. Juan Carlo
s Díaz T
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40
Laboratory studies are normal except for an elevated mean corpuscular volume (MCV), which might suggest:
a) Pheochromocytoma.( ) True ( ) False
b) Pernicious anemia.( ) True ( ) False
DR. J
CDT
Dr. Juan Carlo
s Díaz T
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41
c) Hypothyroidism.( ) True ( ) False
d) Alcoholism.( ) True ( ) False
e) Hyperaldosteronism. ( ) True ( ) False
DR. J
CDT
Dr. Juan Carlo
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42
Two weeks later, the patient is brought to the emergency department because he fell while inebriated. He has rib fractures and a pneumothorax, and is hospitalized with a chest tube in place.
On the second day of hospitalization, he shows signs of agitation and you consider the diagnosis of alcohol withdrawal.
DR. J
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Dr. Juan Carlo
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Which additional signs and symptoms would support this diagnosis?:
a) Tachycardia. ( ) True ( ) False
b) Abdominal cramping.( ) True ( ) False
c) Tremor. ( ) True ( ) False
DR. J
CDT
Dr. Juan Carlo
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d) Hallucinations.( ) True ( ) False
e) Seizures. ( ) True ( ) False
e) Lacrimation and rhinorrhea. ( ) True ( ) False
DR. J
CDT
Dr. Juan Carlo
s Díaz T
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45
The diagnosis of delirium tremens (DTs) is suggested when symptoms progress to which of the following:
a) Ataxia. ( ) True ( ) False
b) Severe tremor ( ) True ( ) False
DR. J
CDT
Dr. Juan Carlo
s Díaz T
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c) Severe confusion and disorientation.( ) True ( ) False
DR. J
CDT
Dr. Juan Carlo
s Díaz T
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47
Case # 187
A 73-year-old white female comes to your office with a 2-day history of severe, relentless back pain. There is no history of trauma. Pain on fist percussion is elicited over the mid -thoracic spine. Pain is also elicited by pushing downward on the patient's shoulders while she is sitting.
DR. J
CDT
Dr. Juan Carlo
s Díaz T
orre
48
In addition to radiographs of her spine, measures that you would consider essential for evaluating the patient at this visit include:
a) Neurologic examination of the lower extremities.
( ) True ( ) False
b) Lumbar puncture ( ) True ( ) False
DR. J
CDT
Dr. Juan Carlo
s Díaz T
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49
c) Dual-photon densitometry. ( ) True ( ) False
The radiographs show relatively lucent vertebral bodies, with accentuation of their cortical outlines. A vertebral body compression fracture with anterior wedging is noted at T8. With this additional information, you are now particularly interested in uncovering potential predisposing or etiologic factors for her problem.
DR. J
CDT
Dr. Juan Carlo
s Díaz T
orre
50
Findings that would be important in this regard include which of the following?:
a) Gout.( ) True ( ) False
b) Chronic corticosteroid use.( ) True ( ) False
c) 50-pack-year cigarette use. ( ) True ( ) False
DR. J
CDT
Dr. Juan Carlo
s Díaz T
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51
Additional studies indicated include:
a) Serum calcium. ( ) True ( ) False
b) Thyroid function. ( ) True ( ) False
c) Creatinine clearance determination. ( ) True ( ) False
DR. J
CDT
Dr. Juan Carlo
s Díaz T
orre
52
Your evaluation uncovers no other problems. Acute management should now include:
a) Analgesics. ( ) True ( ) False
b) Referral to an orthopedist. ( ) True ( ) False
DR. J
CDT
Dr. Juan Carlo
s Díaz T
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53
c) Transcutaneous nerve stimulation.( ) True ( ) False
DR. J
CDT
Dr. Juan Carlo
s Díaz T
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54
Case # 188
Six months ago, a healthy 46-year-old white male computer programmer had a chemistry profile performed at his place of employment and it showed an AST (SGOT) level of 160 U /L (N 7- 27) .He has not come to see you until now because he has "just been too busy. " The report shows normal results for total bilirubin, alkaline phosphatase, creatine kinase, glucose, creatinine, and thyroxine.
DR. J
CDT
Dr. Juan Carlo
s Díaz T
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55
You obtain a history significant for consumption of raw oysters several times a year and one blood transfusion, 6 years ago. His history is negative for foreign travel, alcohol or other drug use, family history of liver disease, sexual activity with other men, symptoms of systemic illness, and gastrointestinal complaints. He has not received any hepatitis immunizations. His physical examination is normal.
DR. J
CDT
Dr. Juan Carlo
s Díaz T
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56
True statements regarding this situation include which of the following?:
a) Hemochromatosis may present in this way. ( ) True ( ) False
b) The test results suggest biliary obstruction.
( ) True ( ) False
DR. J
CDT
Dr. Juan Carlo
s Díaz T
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57
c) Elevated AST may be a normal finding in men with a large muscle mass. ( ) True ( ) False
d) Steatohepatitis could cause this enzyme pattern.
( ) True ( ) False
DR. J
CDT
Dr. Juan Carlo
s Díaz T
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58
You obtain further laboratory tests with the following results: Hepatitis B surface antigen....negative Hepatitis B surface antibody...positive Hepatitis B core antibody. ......positive Hepatitis A antibody………. IgG positive
IgM negative
From these tests you can tell the patient that:
DR. J
CDT
Dr. Juan Carlo
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a) He has had hepatitis A in the past. ( ) True ( ) False
b) He has either chronic active or chronic persistent hepatitis B.
( ) True ( ) False
c) He received blood contaminated with hepatitis B 6 years ago.
( ) True ( ) False
DR. J
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Dr. Juan Carlo
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d) He is not currently infectious with hepatitis B.
( ) True ( ) False
DR. J
CDT
Dr. Juan Carlo
s Díaz T
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61
Additional studies show normal serum ceruloplasmin, ferritin, and alpha1-antitrypsin levels. Findings are normal on hepatic ultrasonography. A liver biopsy shows changes of chronic hepatitis. Antibody to hepatitis C is positive .
True statements you could make to the patient include which of the following?:
DR. J
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Dr. Juan Carlo
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62
a) There is currently no treatment for hepatitis C.
( ) True ( ) False
b) He is no longer contagious for hepatitis C. ( ) True ( ) False
DR. J
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Dr. Juan Carlo
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c) Hepatitis C antibodies are found in the majority of patients with non-A, non-B hepatitis.
( ) True ( ) False
DR. J
CDT
Dr. Juan Carlo
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64
That’s it, folks !
DR. J
CDT
Dr. Juan Carlo
s Díaz T
orreGracias por su atención
Dr. Juan Carlos Díaz Torre Pediatra Neonatólogo
[email protected](779) 100 – 40 - 26
65
