Case study

[USCguy]

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I have to do this clinical thing for a class of mine. I have no idea what is up seeing as I'm not in med school yet. so, if anyone wants to throw a hint my way, much appreciated...we are supposed to come up with which labs we should order and what we think it might be. Also, I'm not really sure which info is tied together and what is just filler designed to throw us off. My guess is to order a metabolic profile(thats about the extent of my lab knowledge) and give a diagnosis of Crohn's (sounds good to my inexperienced ears, but I know I left a WHOLE bunch out). I know I need to read up on all this stuff so that I can do my own "differential diagnosis," and thats what I'll do, just wanted to throw this out there...

A 41 year old trader in exotic birds, who has spent the last 15 years in Central and South America collecting specimens of endangered species, is referred to your hospital by his personal physician with a diagnosis of suspected chronic amoebic dysentery. His symptoms began several years ago, with a dradual onset. Among the symptoms were intermittent episodes of diarrhea, with abdominal discomfort and 5-10 stools daily. Despite this, he maintained a healthy appetite and continued to work. they symptoms gradually increased until he finally sought medical treatment. he has lost 45 pounds and is essentially disabled. He was sent back to the US for treatment. he now complains of continual abdominal cramps, loss of appetite, and frequent bloody stools. he states that the pain is most noticeably located in the upper right abdomen and lower right chest, with radiating pain occasionally experienced in the right shoulder and neck. The chest pain is quite severe and is exacerbated by moderately deep inspiration. In addition, the patient has recently developed a hacking cough with produces large quantities of reddish brown, bloody sputum.

On examination, the patient is patently malnourished, weighing only 115 pounds and standing 6'3'' tall. he is dehydrated, listless, has a fever of 102 degrees, and has a marked "sick" affect. On palpation, the entire abdomen seems quite sore, with severe tenderness in teh right upper abdomen. The liver appears to be enlarged and palpable well below the costal margin, with the area of greatest sensitivity over the lower anterior intercostal spaces on the right side. percussion and ausculatation of the lungs shows signs of marked lung involvement, including rales and dullness on percussion. the right hemidiaphragm also appears to be immobile, and a CBC shows highly elevated white cell count.

Apologies for anything misspelled!

 

[curlycorday]

I think this is way over your head (you're not in med school?)..... Your answer should be: I will stabilize patient and refer to Internal Med/GI/Infectious disease...😉

 

[Bertelman]

Mmmmm...brings fond memories of the Step2 test I took two days ago. Like the previous poster, I too am curious exactly which class it is that you are taking if you're not in med school.

Anyways, to answer one part of your question, I would treat the story as though every word is somehow important. All of these symptoms could certainly be related to his lifestyle, i.e. birdbrain. At the very least, knowing this information should lead you to explore a possible zoonotic disease.

p.s. don't go into this thinking you want to prove one diagnosis (Crohn's). Think of the other likely disease that you need to DISprove. He needs more than just bloodwork.

 

[USCguy]

The class is called Transitioning to Medical School. This thing is an introduction to PBL. I know we aren't supposed to know everything, but I guess they want to get us used to doing this or something 😉

 

[DrWanahbe]

My guess is that he may have picked up a parasite of some kind either from a bird or from being in South America.

I'm not sure what labs I'd order, but I think I'd do a few blood, sputum, and stool cultures. Oh, and some LFTs to check liver function.

For the record, I'm not in med school either, so my ideas don't have a lot of credibility. Yet. 😀

 

[SCER2005]

First of all, the correct test answer would be get more history and physical. Meaning past medical history, surgeries, current meds, allergies, alcohol/tobacco and drug use, etc. Family medical history would be useful as well. Also, a complete set of vital signs with BP, pulse, respiratory rate and pulse oximetry would be helpful. Better description of abdominal pain is a MUST. Does he have rebound or peritoneal signs suggesting a surgical abdomen?

As for as lab testing: CBC with differential, complete metabolic profile (includes liver function tests), chest x-ray. Stool studies including fecal leukocytes, ova & parasites. Digital rectal exam for occult blood as well. Consider CT of the abdomen, however, in this case I would start with a right upper quadrant ultrasound. Draw 2 sets of blood cultures and start the patient on a broad spectrum antibiotic such as Zosyn.

My top 3 differential diagnosis would include: Giardiasis (Giardia lamblia is the causative organism), Ascending Cholangitis, Pneumonia. Giardiasis is what sounds like is being described here so I would also start him on Flagyl as well. The stool ova and parasites is the primary test needed to cinch the diagnosis.

Hope this helps and hopefully it's not too far off. Good luck with your class and the challenging years to come. I would do it all over again in a minute. Let me know if I can be of any additional help.