Patient: 39-year-old male with a history of back pain
Chief Complaint: Patient brought to the emergency department via ambulance due to decreased
level of consciousness, nausea and vomiting
History of Present Illness: Patient had history of spinal fusion secondary to spinal injury
approximately 2-3 years prior to this admission. He subsequently had a history of severe chronic
back for which he had been prescribed a variety of narcotic analgesics and muscle relaxants. He
had been prescribed methadone 1 month prior to admission, but ran out over a weekend and began
taking previously prescribed medications. According to family members, he took an estimated 12
hydrocodone/acetaminophen pills and 6 carisoprodol pills per day for the 3 days immediately prior
to this admission.
Social history: The patient’s family claimed he had no history of acute or chronic alcoholic abuse.
Physical examination: The patient appeared mildly confused and diaphoretic and was noted to
have mild tremors.
Principal Laboratory findings: See Table 1 below.
Patient Outcome: Patient deteriorated rapidly. Developed DIC and acute renal failure. On the 4 th
hospital day, he developed cardiopulmonary arrest and multi-organ failure leading to death.
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Case 1 – Table 1
Question 1 – At admission, what are this patient’s most striking laboratory results?
Question 2 – What is the significance of the patient’s elevated serum amylase and lipase on the
second hospital date?
Question 3 – Based on admission results, what is this patient’s most likely diagnosis?
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Case Study 2
Patient: 45-year-old African American woman
Presentation: Sudden death
History of Present Illness: The decedent was found unresponsive in bed one morning. She was
transported to the hospital, could not be revived and was pronounced dead a few minutes after
arrival.
Past medical/surgical history: Medications prescribed to the decedent suggested a past history of
hypertension. The decedent was treated previously for TB and 3 years after this treatment, a
cavitary lung lesion was found. Subsequently, 3 sputum samples were obtained and examined by
Ziehl-Nielsen staining for acid-fast bacilli. No AFB were observed, however a purified protein
derivative (PPD) test was strongly positive at this time. The patient was treated with 4-drug therapy
(isoniazid, rifampin, ethambutol, and pyrazinamide). Several years prior to this most recent hospital
admission, the decedent underwent an open reduction of a mandibular fracture and repair of a facial
laceration following facial trauma with a tire iron. She was left with a residual facial nerve palsy.
Social History: The decedent was single with 1 adult daughter. She had a history of alcohol and
drug abuse and had been a heavy smoker.
Autopsy Findings: The decedent’s body was that of an obese (247 lbs) African-American woman
with medium brown skin. The heart was not enlarged with respect to body size. The lungs were
normal in weight and configuration. The right lung was adherent to the diaphragm and a single,
minute granuloma without necrosis was seen only on microscopic examination. The adrenal glands
were enlarged bilaterally with a thick, nodular cortex and a firm yellow-tan cut surface and a focal
calcification was evident in both glands. The right lobe of the liver contained a 2-cm subcapsular
nodule beneath the surface. Microscopically, the adrenal glands were nearly completely destroyed
by granulomatous inflammation with caseating necrosis. Microscopic examination of the liver and
peritoneal nodules revealed that these nodules were granulomas. Staining of these tissues for acid-
fast bacilli and for fungi was negative.
Additional History: After discussing the autopsy findings with the decedent’s daughter, she
mentioned that the mother’s skin had been getting darker in the months preceding her death.
Principal Laboratory Findings: See Table 1 below.
Case 2 – Table 1
Test Patient’s Result Reference Interval
Vitreous Fluid
Sodium
Potassium
Serum
Cortisol
127
10.3
4
1.5-2.5 hours post-mortem
135-151 mEq/L
4.2-7.0 mEq/L
10-25 µg/dL
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Question 1 – What is the most likely diagnosis consistent with this patient’s autopsy histopathologic
findings?
Question 2 – What is the relationship between TB and the disease identified in question 1?
Case Study 3
Patient: 20-year-old African American woman
Chief complaint: Fever (102) and cough that were not responding to amoxicillin treatment.
Patient was lethargic and wheel chair bound.
History of present illness: Four days prior to presentation at the ER, the patient’s mother noticed
her daughter’s cough and fever. The patient was seen by a primary care physician who prescribed
amoxicillin. However, despite 4 days of treatment with amoxicillin, the patient showed no signs of
improvement.
Past Medical History: Neurological problems due to meningitis at 3 months of age.
Family/Social History: Non-contributory, no history of illicit drug, ethanol, or tobacco use.
Current medications: Depakote (valproic acid 250mg bid) for seizures.
Physical Exam Findings: Non-ambulatory (wheel chair bound), resists manipulation, was non-
verbal.
Principal Laboratory Findings: See Table 1 below.
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Case 3 – Table 1
Question 1 – What is (are) this patient’s most striking clinical and laboratory findings?
Question 2 – What is this patient’s most likely diagnosis?
Question 3 – What are the appropriate specimen collection and handling procedures for ammonia
testing?
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Case Study 4
Patient: 42-year-old African American man.
History of Present Illness: The police found him lying naked in a ditch, the victim of an apparent
assault. He had multiple signs of trauma, including numerous bruises and abrasions on his face and
extremities. He was conscious but was confused and combative.
Physical Examination: The patient’s vital signs were: temperature, 96.8; pulse 72 beats/min;
blood pressure, 131/88 mmHg. He could follow verbal commands but could not communicate. He
had a swollen upper lip and limitation in his ability to open his mouth. There was no evidence of
any other abnormalities. He was admitted to the hospital for further evaluation.
Past Medical History: Seven years ago, he was diagnosed with HIV/AIDS. In addition, he had
been treated for Pnemocystis carini (PCP) pneumonia 4 months prior to this current hospitalization
during which time his HIV viral load was 330,000 copies.
Principal Laboratory Findings: See Table 1 and 2 below.
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Case 4 – Table 1
Case 4 – Table 2
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Question 1 – What are this patient’s most striking lab findings?
Question 2 – What is the most likely explanation for this patient’s extremely low and undetectable
creatinine levels?
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