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Case 1.

1 A 72-year-old man goes to the doctor complaining of painless swelling of both legs
which he first noted approximately 2 months ago. The swelling started at the ankles but now
his legs, thighs and genitals are swollen. His face is puffy in the mornings on getting up. His
weight is up by about 10 kg over the previous 3 months. He has noticed that his urine appears
to be frothy in the toilet. He has noted gradual increasing shortness of breath, but denies any
chest pain. He has also developed spontaneous bruising over the past 6 months. He continues
to smoke 30 cigarettes a day. His medication consists of atenolol 50 mg once a day. On
examination there is pitting oedema of the legs which is present to the level of the sacrum.
There is also massive oedema of the penis and scrotum. There is bruising on the forearms and
around the eyes. There are no signs of chronic liver disease. His pulse rate is 72/min and
regular. Blood pressure is 166/78 mmHg. There is dullness to percussion and reduced air
entry at both lung bases. The liver, spleen and kidneys are not palpable, but ascites is
demonstrated by shifting dullness and fluid thrill.
Laboratory tests:
Haemoglobin 10.7 g/dL Creatinine 1.12mg/dL
Mean corpuscular volume (MCV) 95 fL Glucose 87 mg/dL
White cell count 4.7 x109/L Total proteins 4.6 g/dL
Platelets 176 000/mm3 Cholesterol 400 mg/dL
Sodium 138 mmol/L Triglycerides 180 mg/dL
Potassium 4.9 mmol/L Clotting screen: normal
Urea 54 mg/dL Urinalysis: protein; no blood

Case 1.2 Mr. Worried is a 52-year-old widow. He is retired and living alone. He enters the ED
complaining of shortness of breath and tingling in fingers. His breathing is shallow and rapid
(RR 36/min). He denies diabetes; blood sugar is normal. There are no EKG changes. He has
no significant respiratory or cardiac history. He takes several antianxiety medications. He says
he has had anxiety attacks before. While being worked up for chest pain an ABG is done:
Arterial blood gases results are:
pH= 7.48 PaO2= 85
PaCO2= 28 Sodium 141 mmol/L
HCO3= 22 Potassium 4.6 mmol/L

Case 4.1. A 47 years old male patient goes to a clinic on for history of polydipsia in recent
weeks, for which he had been drinking large quantities of water, and weight loss evan if he
was eating more than usual. He was diagnosed with hypertension 5 years ago and received
treatment. He smokes 1 pack per day for the past 10 years and drinks 4-5 beers/day. He
reports a very sedentary lifestyle with no regular exercise or physical activity. His mother had
myocardial infarction at age 60. Father underwent coronary artery bypass (CABG) at age 59
due to severe 3 vessel disease. Other brother died of myocardial infarction at age 40. Physical
examination: BP = 160/100 mmHg, Wt = 120 kg, height 165cm, HR = 70 bpm. His random
blood sugar was 305mg/dL as measured by glucometer.
Laboratory tests:
HbA1c level of 9.9%, Potassium 4.6 mmol/L
Fasting blood glucose level of 202 mg/dL Total cholesterol = 380 mg/dL
Haemoglobin 15.3 g/dL LDL-C = 276 mg/dL
White cell count 7.4 x 109/L HDL-C = 28 mg/dL
Platelets 328 000/mm3 Trigs = 380 mg/dL
Sodium 141 mmol/L
Case 4.2. A 35 year old woman is seen for easy fatigue for many months. She is now 24
weeks pregnant with her 3rd child in 3 years. She does not see any obstetrician and does not
take any vitamins. She has no other complaint. Family and past history are negative. Physical
examination is positive for pale conjunctiva, mild spooning of nails, and a II/VI systolic
murmur at left lower sternal border. Stools are negative for occult blood. Labs: Complete
blood count - Hg 7.1 gm/dl, Hct 23%, WBC 5,400/mm3, platelets 450,000/mm3; Mean
Corpuscular volume is 74 fl (normal 85-95 fl).
Case 2.1 A 25-year-old white female presents to the emergency room because of sharp left-
sided chest pain and shortness of breath for the past day. The patient was in excellent health
until yesterday. She was awakened from sleep by the sharp left-sided chest pain. The pain
worsened with motion and deep breathing. Presently, she complains of shortness of breath and
is very apprehensive about dying. She denies any cough, fever, or sputum production, but has
had one episode of hemoptysis earlier today and, upon further questioning, notes some
swelling and tenderness of the left calf. She is married and had one normal delivery three
years ago. She is taking birth control pills. She has never been hospitalized except for
delivery of her first child. The patient does recall having a left ankle fracture 3 months ago
with a cast in place for 6 weeks. A review of systems is negative. She denies any history of
venous problems. She works as a computer programmer. She has smoked one pack of
cigarettes a day for the past eight years.
Physical examination: Blood pressure 102/80; pulse 128; respiratory rate 32; oral temperature
37.0 C. ABG (on room air) reveals: pH 7.48, PCO2 30, PO2 80, HCO3- 22
Haemoglobin 15.3 g/dL Potassium 4.6 mmol/L
White cell count 7.4 x 109/L Urea 26 mg/dL
Platelets 328000/mm3 Prothrombin time: normal
Sodium 141 mmol/L D-dimers: 10557 ng/mL

Case 2.2. A 26-year-old male was admitted to the hospital complaining of generalized muscle
soreness. He had completed a 50 KM marathon, three days prior to admission. He has become
progressively anorexic and lethargic. He also noticed a decreasing amount of urine output
over the past three days. Medical history: Unremarkable and he was not taking any
prescription or over the counter medication. He denied alcohol and illicit drug use. Laboratory
Data: Serum: Sodium 138 meq/L, potassium 7.0 meq/L; chloride 101 meq/L, total Urea 150
mg/dl; creatinine 10 mg/dl; glucose 100 mg/dl.

Case 3.1. A 27-year-old woman is admitted to the emergency department complaining of pain
across her back. She became unwell 2 days previously when she started to develop a fever
and an ache in her back. The pain has become progressively more severe. She has
vomited twice in the past 6 h. She has had no previous significant medical history, apart
from an uncomplicated episode of cystitis 3 months ago.
On examination she looks unwell and is flushed. Her temperature is 39.5°C. Her pulse is 120
beats/min and blood pressure 104/68 mmHg. Examination of the cardiovascular and
respiratory systems is unremarkable. Her abdomen is generally tender, but most markedly in
both loins. Bowel sounds are normal.
Investigations:
Haemoglobin 15.3 g/dL Creatinine 0.9 mg/dL
White cell count 25.2 x 109/L C-reactive protein (CRP) 316 mg/L
Platelets 406 000/mm3 Urinalysis: '' protein; ''' blood; '' nitrites
Sodium 134 mmol/L Urine microscopy: >50 red cells; >50
Potassium 4.1 mmol/L white cells;
Urea 24 mg/dL
Abdominal X-ray: normal

Case 3.2 A 24-year-old patient presented to the hematology clinic for follow-up after a recent
hospitalization for excessive bleeding from an accidental knife cut. The patient reported a
history of prolonged bleeding after teeth extractions, an upper gastrointestinal bleed 3 years
previously, and excessive bruising since childhood. He denied hemarthroses but reported
chronic pain in his ankles and joints. Initial laboratory test results included a normal complete
blood count, including platelets, a partial thromboplastin time (aPTT) of 50 s, and a
prothrombin time (PT) of 30 s. Low activity of factor VIII was found.
Case 5.1. A 10-year-old white female patient was brought to the Emergency Room by her
mother because of shortness of breath and wheezing. She claims that these symptoms have
been worse for the past two months. Recently, she complains of more frequent and severe
attacks in addition to a persistent cough which has been especially troublesome at night. She
complains of chest tightness but denies fever. She also reports seasonal rhinitis, most
noticeable in the summer months, until the first frost. The physician notes that the patient is in
moderately severe respiratory distress and is unable to lay flat. Vitals: BP 150/90, HR = 120,
RR = 34, T = 37.0. Accessory muscle use was noted, as well as diffuse inspiratory and
expiratory wheezing. The rest of the exam was normal. A pulseoximeter revealed an oxygen
saturation of 91% on room air. Peak Flow was 100 liters/min. The ER physician orders the
following: oxygen - by nasal cannula and bronchodilators with a reliefe of the symptoms.
ABG (on room air) reveals: pH 7.55, PCO2 30, PO2 63, HCO3- 22
One month after discharge, the patient obtains the following pulmonary function tests (PFT's):
Pre-Bronchodilator
Post-Bronchodilator
(% Predicted)
FEV 1 1.9 L (81%) 2.5 L
FVC 3.3 L (55%) 4.2 L
FEV 1 /FVC .57
TLC 6.3 L (105%)
RV 3.0 L (120%)
DLCO 22.3 (112%)

Case 5.2 A 56 year old man with a history only notable for mild hypertension presents with
calf discomfort and left lower extremity swelling. One day earlier he returned to Washington,
DC on a long haul flight from Tokyo, Japan. On review he denies chest pain and shortness of
breath. He has no other pertinent history. On physical examination his blood pressure is
125/80, pulse 85, and respiratory rate is 14 with an oxygen saturation of 99% on room air. His
left leg is swollen to the knee. Lab test: white cell count 7.4 x 109/L, platelets 328 x 109/L
D-dimers: 8557.

Case 8.1 A 38-year-old woman presents to the doctor complaining of pains in her joints and
fatigue. She has noticed these pains worsening over several months. Her joints are most stiff
on waking in the mornings. The joints that are most painful are the small joints of the hands
and feet. The pain is relieved by anti-inflammatory drugs. She has had no previous serious
illnesses. She is married with two children and works as a legal secretary. She is a non-smoker
and drinks alcohol only occasionally. On examination she looks pale and is clinically
anaemic, her interphalangeal joints and metacarpophalangeal joints are swollen and painful
with effusions present. Her metatarsophalangeal joints are also tender. Physical examination is
otherwise normal.
Haemoglobin 8.9 g/dL Erythrocyte sedimentation rate (ESR) 78
Mean corpuscular volume (MCV) 87 fL mm/h
White cell count 7.2 x 109/L Sodium 141 mmol/L
Platelets 438 000/mm3 Potassium 3.9 mmol/L
Case 8.2. An 18-month-old girl presented to the Emergency Department with depressed
consciousness, comatose state, pale skin with peripheral cyanosis and tachypnea. Her initial
assessment revealed a heart rate of 155/min with thread pulse, respiratory rate of 60/min with
Kussmaul breathing, dry mucous membranes, sunken eyes, poor capillary return, and cold
fingers and toes. Laboratory testing: serum glucose 605 mmol/L, venous pH 6.9, bicarbonates
4.8 mmol/L, Na 138 mmol/L, K 3.5 mmol/L, L 12000 /mm3, urea 85 mmol/L, creatinine 3.5
mg/dL and ketonuria +++.

Case 6.1. A 36-year-old man presents to the emergency room for dizziness, sweating,
headache and anxiety. The patient reports that he is currently homeless and has lost syringes,
glucose meter, and related glucose testing supplies but he took he took 50 U of insulin in the
morning. He is known with hypertension and retinopathy. The patient states that 6 years ago
he was diagnosed with diabetes as he was hospitalized with a glucose value >1000 mg/dL and
he was experiencing polyuria, polydipsia, and polyphagia. He reports that he has been on
insulin since the time of his diagnosis, and he has never been prescribed oral agents for
diabetes management. In the medical records it is mentioned that the C-peptide value and
insulinemia were low. When asked about meal, the patient relates that he is currently
homeless and eats when food is available, often snacking on bits of food throughout the day.
He was not using a meal dose of insulin aspart, but he would use this insulin to correct for
hyperglycemia.
Laboratory values on admission
Haemoglobin 15.3 x g/dL Trigs = 380 mg/dL
White cell count 8 x 109/L Blood sugar = 38 mg/dL
Platelets 406 000/mm3 HbA1c: 11.3%
Sodium 134 mmol/L Creatinine: 1.3 mg/dL with eGFR =53
Potassium 4.1 mmol/L mL/min
Total cholesterol = 380 mg/dL Urea 40 mg/dL
LDL-C = 276 mg/dL Albuminuria 350 mg/dL (6 month ago it
HDL-C = 28 mg/dL was 310 mg/dL)

Case 6.2 35-year-old male patient presents to ED with fever and cough with purulent
secretions. Physical examination: His body temperature is 38.9°C (100°F), his pulse is 110
beats/min and regular, and his respiratory rate is 25 breaths/min. His oxygen saturation is 91%
while breathing room air. There is mild erythema of the mucosa of the nose and posterior
oropharynx. Inspiratory “rales” are heard at the right lung base. Laboratory and radiographic
findings: hemoglobin level is 12.5 g/dL, with a hematocrit of 36%. His WBC count is 13,500
cells/mm3, with 82% polymorphonuclear cells, 11% band forms, and 7% lymphocytes. His
platelet count is 180,000 cells/µL. The results of a multichemistry screen are unremarkable.
Chest radiography documents bilateral lower lobe infiltrates that are more pronounced on the
right side. There are no pleural effusions.

Case 7.1. A 46 years old male patient was referred to a nephrologist due to complaints on dry
mouth, polydipsia, polyuria and deterioration in renal function. The patient started to receive
lithium at the age of 28 years after being diagnosed as having bipolar disorder. His clinical
assessment at the nephrology clinic revealed the following findings: blood pressure was
normal;
Laboratory values on admission:
Haemoglobin 12.2 g/dL Plasma creatinine =1.4 mg/dl,
Mean corpuscular volume (MCV) 85 fL Urea =34 mg/dl,
White cell count 6.7 x 109/L Sodium =139 mEq/L;
3
Platelets 312 000/mm eGFR =57 ml/min;
Urine output =8 L/day, without proteinuria, glucosuria, red blood cells or casts;
Kidney ultrasound was normal. After an initial examination, a water deprivation test was
performed revealing the following results: before the test – plasma osmolality =283 mOsm/
kg, urine osmolality =164 mOsm/kg; 6 hours after water deprivation – plasma osmolality
=298 mOsm/kg, urine osmolality =165 mOsm/kg; after administration of vasopressin – urine
osmolality =174 mOsm/kg. After the test lithium was stopped and the patient was switched to
other psychotropic drugs (such as valproate, carbamazepine, antipsychotics).

Case 7.2 A 44-year-old Caucasian woman was referred to the Lipid and Obesity Clinic by her
family doctor due to increased total cholesterol and TG levels. The patient denied any
symptoms indicative of cardiovascular disease. Physical examination revealed tuberous
xanthomas over the patient’s elbows (they were also present on his knees). Laboratory
assessment revealed: fasting plasma glucose: 300 mg/dL, TC: 1055 mg/dL, TG: 2900 mg/dL,
HDL-C: 18 mg/dL, VLDL-C: 316 mg/dL, VLDL-TG: 831 mg/dL Secondary causes of
dyslipidemia were excluded.

Raspunsuri:

1.1 Sindrom nefrotic


1.2 Alcaloza respiratorie
2.1 Embolie pulmonara cu alcaloza respiratorie
2.2 insuficienta renala acuta post effort fizic sustinut
3.1 Pielonefrita acuta (inflamatie)
3.2 Hemofilia A
4.1 DZ tip II, dislipidemie, syndrom metabolic
4.2 Microcytic hypochromic anemia
5.1 Astm bronsic cu alcaloza respiratorie
5.2 Tromboza venoasa profunda
6.1 Diabet zaharat tip I, hipoglicemie, dislipidemie, retinopatie, nefropatie
diabetica.
6.2 PNEUMONIE LOBARA BILATERALA
7.1 Diabetus insipid neurogen secundar tratamentului cu litiu
7.2 disbetalipropoteinemie
8.1 poliatrita reumatoida si anemie secundara inflamatiei cronice
8.2 DZ tip I, cetoacidoza diabetica.