PD2 Final Exam Merged

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CASE 1

This is a case of a 33 year old female who came in at the ER due to chills. Condition started 3
days prior to consult when the patient started to complain of terminal dysuria associated with
hesitancy and incomplete voiding.

2 days prior to consult, patient also noticed “flushed” feeling, associated with headache, nausea
and vomiting. Few hours prior to consult, patient complained of chills that seems “not to go away”.

Past Medical History:


Non diabetic, non hypertensive. Bronchial Asthma, last attack last month, no controller.
Family History:
Maternal history of Diabetes and Hypertension.
Paternal history of Colon Cancer.
ROS: Unremarkable.
Physical Examination:
BP: 110/80 HR: 89 RR: 24 Temp: 38.9
Patient is awake, ambulatory, conscious and coherent, acutely ill
looking, not in cardiorespiratory distress.
Skin appears flushed, without noticeable localized lesions. No rashes.
No cervical lymphadenopathy. Posterior pharyngeal walls appears
hyperemic but not congested. Tonsils are not hyperemic and not
enlarged.
Chest expansion is symmetrical without use of accessory muscles of
inspiration. Tactile remits are equal. Breath sounds are mostly
vesicular. No crackles, no egophony.
Dynamic precordium, tachycardia with regular rhythm. Good S1/S2, no
murmurs noted.
Abdomen is flat without noticeable lesions and discoloration,
normoactive, soft and non tender.
There is bilateral tenderness on striking the Costovertebral angle.
Pulses are equal, 2+ on all extremities. No bipedal edema.

QUESTIONS:
1. What else in the history would you like to ask the patient that would help you in
narrowing her diagnosis? (4 points each, 20 points total)
1. Sexual history
2. LMP, and if currently pregnant
3. Work: sex worker? Guest relation officer?
4. Personal hygiene
5. Use of birth control? Spermicides?

2. What are her differential diagnosis? (4 points each, 20 points total)


1. Acute uncomplicated cystitis
2. Acute pyelonephritis
3. Sexually transmitted infection
4. Nephrolithiasis
5. Pelvic Inflammatory Disease

3. Final Diagnosis (10 points)


1. Acute (Uncomplicated) Pyelonephritis

4. What laboratory and ancillary test would you request? (5 points each, 20 points total)
1. CBC platelet count
2. Urinalysis
3. Urine Culture and Sensitivity
4. KUB Ultrasound

5. Prescribe an antibiotic for the patient (10 points)


Antibiotics: any of these
a. Ciprofloxacin 500mg tablet BID for 7days (or 1000mg tablet OD
for 7 days)
b. Levofloxacin 250mg OD for 7 days (or 750mg OD for 5 days)
c. Ofloxacin 400mg BID for 14 days
d. Cefixime 400mg OD for 14 days
e. Ceftibuten 400mg OD for 14 days
f. Cefuroxime 500mg BID for 14 days
g. Coamoxiclav 625mg TID for 14 days

6. Provide health education to the patient to prevent recurrence (4points each, 20 points
total)
a. Drink plenty of water
b. Sexual hygiene (wash genitalia before and after sex, urinate
after sex)
c. Don’t hold your urine
d. Wash your rectum daily and from front to back
e. Proper perineal hygiene (do not use vinegar, or harsh soap)

CASE 2
This is a case of BB 19 year old female who came to you due to hesitancy. Condition started 2
days prior to consult when the patient started to notice incomplete voiding without associated
fever. 1 day prior to consult, patient also experience hesitancy which prompted consult.

Past Medical History:


Non diabetic, non hypertensive.
Bronchial Asthma, last attack last month, no controller.
Family History:
Maternal history of Diabetes and Hypertension.
Paternal history of Colon Cancer.
ROS: Unremarkable.
Physical Examination:
BP: 110/80 HR: 89 RR: 24 Temp: 36.9
Patient is awake, ambulatory, conscious and coherent, acutely ill
looking, not in cardiorespiratory distress.
Skin appears flushed, without noticeable localized lesions. No rashes.
No cervical lymphadenopathy. Posterior pharyngeal walls appears
hyperemic but not congested. Tonsils are not hyperemic and not
enlarged.
Chest expansion is symmetrical without use of accessory muscles of
inspiration. Tactile remits are equal. Breath sounds are mostly
vesicular. No crackles, no egophony.
Dynamic precordium, tachycardia with regular rhythm. Good S1/S2, no
murmurs noted.
Abdomen is flat without noticeable lesions and discoloration,
normoactive, soft and non tender.
No CVA tenderness noted.
Pulses are equal, 2+ on all extremities. No bipedal edema.

QUESTIONS:
1. What else in the history would you like to ask the patient that would help you in
narrowing her diagnosis? (4 points each, 20 points total)
1. Sexual history
2. LMP, and if currently pregnant
3. Work: sex worker? Guest relation officer?
4. Personal hygiene
5. Use of birth control? Spermicides?

2. What are her differential diagnosis? (4 points each, 20 points total)


1. Acute uncomplicated cystitis
2. Acute pyelonephritis
3. Sexually transmitted infection
4. Nephrolithiasis
5. Pelvic Inflammatory Disease

3. Final Diagnosis (10 points)


1. Acute (Uncomplicated) Cystitis

4. What empiric first line antibiotic would you prescribe to this patient (10 points)
First line antibiotics for AUC (any 1 of these)
a. Fosfomycin 3gram sachet single dose.
b. Nitrofurantoin 100mg tablet every 6 hours for 7 days

5. After 3 days, patient comes back to you complaining of persistent hesitancy despite
compliance with your prescribed medication. What would be your next course of action?
(10 points each, 20 points total)
a. Request for a urine culture
b. Replace antibiotics with either a quinolone (levofloxacin,
ciprofloxacin or ofloxacin) or beta lactams (coamoxiclav,
cephalosporin)
6. Provide health education to the patient to prevent recurrence
(4points each, 20 points total)
a. Drink plenty of water
b. Sexual hygiene (wash genitalia before and after sex, urinate
after sex)
c. Don’t hold your urine
d. Wash your rectum daily and from front to back
e. Proper perineal hygiene (do not use vinegar, or harsh soap)

CASE 3
This is a case of CC 35 year old male who came in due to hematuria. Condition started 2 weeks
prior to consult when the patient started to notice lower back pain more pronounced on the left,
without associated fever.

1 week prior to consult, patient also noted initial dysuria with decreased force of urine however
he claims that towards the end of voiding, the dysuria and decrease force of urine would usually
go away. Patient did not sought consult and tried to self medicated with sambong capsule once
a day without relief.

1 day prior to consult, patient complained of blood tinged urine, which prompted consult.

Past Medical History:


Non diabetic, non hypertensive.
Family History:
Maternal history of Diabetes and Hypertension.
Paternal history of Colon Cancer.
ROS: Unremarkable.
Physical Examination:
BP: 110/80 HR: 89 RR: 24 Temp: 36.9
Patient is awake, ambulatory, conscious and coherent, acutely ill
looking, not in cardiorespiratory distress.
Skin appears not flushed, without noticeable localized lesions. No
rashes.
No cervical lymphadenopathy. Posterior pharyngeal walls are non
hyperemic, not congested. Tonsils are not hyperemic and not enlarged.
Chest expansion is symmetrical without use of accessory muscles of
inspiration. Tactile remits are equal. Breath sounds are mostly
vesicular. No crackles, no egophony.
Dynamic precordium, tachycardia with regular rhythm. Good S1/S2, no
murmurs noted.
Abdomen is flat without noticeable lesions and discoloration,
normoactive, soft and non tender.
CVA Tenderness noted on the left.
Pulses are equal, 2+ on all extremities. No bipedal edema.
QUESTIONS
1. What else in the history would you like to ask the patient that would help you in
narrowing his diagnosis? (5 points each, 20 points total)
1. Intake of vitamins (excessive intake of Vitamin C, Calcium)
2. Previous diagnosis of Hyperuricemia, Gout, Hyperparathyroidism
3. Diet (high sugar, high protein, high sodium diet)
4. Work and activities that may increase water loss and promote
dehydration (jeepney drivers, metro aide, traffic aides,
athletes, etc)

2. What are your differential diagnosis (4 points each, 20 points total)


Any five:
1. Acute Complicated Pyelonephritis
2. Benign Prostatic Hyperplasia
3. Prostate Carcinoma
4. STI
5. Non Gonococcal Urethritis
6. Prostatitis
7. Epididymitis

3. What is your most likely diagnosis? (10 points)


1. Neprolithiasis, OR
2. Urolithiasis

4. What laboratory tests, or ancillary procedure would you like to


request? (4 points each, 20 points total)
1. Urinalysis
2. Flat plate of the abdomen, abdominal XRAY.
3. KUB Prostate UTZ
4. IV Pyelography
5. Non contrast Helical CTSCAN, CT Stonogram.

5. How would you manage this case (medical/surgical)? (4 points each,


20 points total)
Any five
1. Analgesia (NSAIDS)
2. Alpha blockers (Tamsulosin, Alfuzosin)
3. Potassium Citrate
4. ESWL
5. Ureteroscopy
6. Percutaneous Nephrolitotomy
7. Nephrectomy

6. How would you advise the patient (2 points each,10 points total)
Any five of the following:
1. Increase oral fluids intake
2. Avoid dehydration
3. Eat less salt, including high sodium foods like canned goods.
4. Limit intake high calcium foods like cheese, milk, yogurt
5. Increase citrate in the diet, such as lemonade, oranges.
6. In uric acid stones, avoid foods high in uric acid.
7. Avoid taking too much Vitamin C, Calcium and Vitamin D more
than the RDA.
8. Limit how much protein you eat. Choose lean meats.

CASE 4
This is a case of a 55 year old male who came in due to bipedal edema. Condition started 1
week PTC when the patient started to notice increasing blood pressure from baseline 120/80 to
180/100 mmHg associated with headache and nape pain. Patient took Amlodipine, 5mg
tablet as advised by his friend.

3 days prior to consult, patient noted, frothy urine, especially


in the morning.

2 days prior to consult, patient also complained of bipedal edema


starting at the ankle but now has progress to mid-leg. This prompted
consult.

Past Medical History:


Non diabetic, non hypertensive.
Bronchial Asthma, last attack last month, no controller.
Family History:
Maternal history of Diabetes and Hypertension.
Paternal history of Colon Cancer.
ROS:
Weight gain >20% in the last week, Body malaise and fever 2 weeks ago.
(+)Hoarseness, (+) cough, (-) colds also 2 weeks ago.
(-) Difficulty of breathing.
(-) Chest pain, (-) palpitations
(-) Abdominal pain, (-) LBM
Physical Examination:
BP: 220/110 HR: 89 RR: 24 Temp: 36.9
Patient is awake, ambulatory, conscious and coherent, acutely ill
looking, not in cardiorespiratory distress.
Skin appears flushed, without noticeable localized lesions. No rashes.
No cervical lymphadenopathy. Posterior pharyngeal walls appears
hyperemic but not congested. Tonsils are not hyperemic and not
enlarged.
Chest expansion is symmetrical without use of accessory muscles of
inspiration. Tactile remits are equal. Breath sounds are mostly
vesicular. No crackles, no egophony.
Dynamic precordium, tachycardia with regular rhythm. Good S1/S2, no
murmurs noted.
Abdomen is flat without noticeable lesions and discoloration,
normoactive, soft and non tender.
No CVA tenderness noted.
Pulses are equal, 2+ on all extremities.
Bipedal edema +2.

Urinalysis Result:
Color Amber to tea
colored
pH 7.35
Specific Gravity 1.035
Leukocytes 20-30/hpf
Red blood cell 30-40/hpf
Bacteria None
Epithelial Cells 10-20/hpf
Glucose Negative
Protein (+) 4
Ketones Negative
Others RBC Cast (+)

QUESTIONS:
1. Interpret the urinalysis (4 points each, 20 points total)
1. Abnormal color, or blood in the urine.
2. Concentrated urine
3. Sterile Pyuria
4. Hematuria
5. Massive proteinuria

2. What are your differential diagnosis (4 points each, 20 points total)


1. Acute complicated pyelonephritis
2. Urolithiasis, Nephrolithiasis
3. BPH, Prostate Malignancy
4. Nephrotic Syndrome
5. Chronic Kidney Disease secondary to Hypertensive Nephrosclerosis

3. Final Diagnosis (10 points)


1. Acute Post streptococcal Glomerulonephritis (give 10 points), OR
2. Acute Glomerulonephritis (give 5 points).

4. Aside from the Urinalysis, what labortary test would you like to
request? (2 points each, 20 points total)
1. Complete blood count
2. Serum Creatinine
3. BUN
4. Complement levels
5. Lipid profile, Cholesterol level
6. ESR, ANA
7. Serum Albumin
8. Serum electrolytes (Potassium)
9. Kidney ultrasound
10. Kidney Biopsy

5. How would you manage this patient? (5 points each, 20 points total)
1. Anti hypertensive medications (Preferably Alpha blocker, followed
by vasodilator and calcium channel blockers: like Clonidine,
Hydralazine, Nifedipine, Diltiazem)
2. Loop Diuretics (Furosemide)
3. Antibiotics (not for UTI) but for sore throat (Co amoxiclav,
Cephalosporins, Quinolones)
4. Calcium supplements

6. What advise can you give to this patient? (2 points each, 10 points
total)
1. Eat less protein
2. Limit salt and potassium in the diet
3. Limit fluid intake
4. Monitor blood pressure regularly
5. Seek prompt consult for sore throat and skin infection
PD: Prelims dynamic,displaced laterally to 6th ICS MCL.
Case: MYOCARDIAL INFARCT Regular rhythm S1>S2 at the apex. +S4
gallop. No murmurs
Case of a 58 year old female who came at the
ER due to chest pain 2.) What are your working diagnosis? Give
1. What other pertinent questions should at least three?
be asked in the Medical History Stable Angina
CC: Chest Pain Unstable Angina
HPI Acute Myocardial Infarction
▪ Onset of chest pain (3 hours PTA)
▪ Location of chest pain? (retrosternal) 3.) What diagnostic test will you request to
▪ Duration confirm your diagnosis?
Character of chest pain? (heavy, squeezing) • ECG
▪ Radiation (Radiating to left subscapular area) • Cardiac Enzymes
▪ Severity (pain scale of 9/10) • Chest X-ray
▪ Timing • 2DED
▪ Associated s/sx? (Diaphoresis)
PMX 4.) Discuss treatment options
▪ Comorbids PCI
1. Hypertension AMI REGIMEN
2. Diabetes Mellitus for 10 years • ASA (aspirin)
3. Previous hospitalization (none) • Clopidogrel
4. Maintenance medications. (unrecalled anti • Beta blockers (Heart rate and BP)
HIN and anti DM; noncompliant) • ARBs/ACE
FHX • Statins
• 1st degree relative with CV death (Father • Nitrate
deceased - stroke) • Anticoagulants
Personal and Social History • Morphine
▪ Smoking Pack years (40 years smoker) • Lactulose
▪ Alcohol Intake (occasional alcoholic drinker) • Oxygen
▪ Lifestyle (Sedentary)
ROS PD 2: Midterms
• Respiratory Case: Pulmonary
• Cardiovascular
• Endocrine A 55-year-old businesswoman, smoker,
PE presents to the emergency room complaining
of productive cough. fever and chest pain for 7
What focus PE? days. She consulted a nearby clinic and
• CARDIOVASCULAR EXAM claimed she was given antibiotics. Her cough
• JVP was noted to have decreased in quantity.
• AUSCULTATE CHEST FOR CRACKLES However, the lever persisted and she was still
experiencing left-sided chest pain, which is
Verbalize: PE findings to student worse when she coughs or takes a deep
General: Conscious but anxious and restless breath. In addition, she started to have
VS: BP 150/100, CAR 110, RR 28, Temp: 36.8 difficulty breathing especially when she walks
Skin: Cool, Clammy around. On PE, Temperature is 38.5 C Heart
Neck: JVP 3 cms/water rate is 115 bpm. BP 120/70 mmHg. RR 26 and
Lung: Equal Lung Expansion. No retractions. is shallow. Pulse oximetry is 94% saturation on
Clear breath sounds room air. Upon auscultation of the chest,
Heart: Dynamic precordium, with no bulging or decreased breath sounds in the lower hat of
depressions. Apical impulse is 2.5 cms in the left lung fields posteriorly
width,

1 scan = 1 prayer na magcclerk ako 1 retype = 1 prayer na magbabago ang cases sa PD


What other focused PE will you do to 2 days prior to consult, pain had become
further assess the patient? continuous but still tolerable.
Percussion A day prior to consult, she noted she was
Tactile Fremitus feverish and felt chilly, for which she took
Vocal Fremitus paracetamol. She had decreased appetite too
Bronchophony, Egophony whispered and pain had increased in intensity.
pectoriloquy
On day of consult, she experienced nausea
Findings Dullness on percussion, Decreased and vomiting. She also noted her skin was
tactile and vocal fremitus yellowing, hence, she finally sought consult.
BP: 110/80 HR 120 RR 20 Temp 38.5° C BMI
Formulate differential diagnoses (20 points) 24 (+) jaundice and icteresia
Abdomen was flat and without lesion.
Pleural effusion Consolidated pneumonia Normoactive bowel sounds.
Pneumothorax
COPD 1. What other focused PE will you do to
further assess the patient? (20 points)
Most likely diagnosis of the case. a. Measure abdominal girth (4points)
Pleural effusion probably secondary b. Percussion for general tympanism
1. CAP and also check liver span (4points)
2 PTB c. Palpation: especially for the Liver (4
points)
Recommend cost-effective diagnostic d. Palpation of the gallbladder
tests. (20 points) (4points)
Chest UTZ e. Check for Murphy’s sign (4points)
Soutum gsics 2. Formulate differential diagnoses
Sputum AFB (20points) Give at least 5
AFB CBC a. Acute Cholelithiasis with cholic pain
b. Acute Cholecystitis
Recommend appropriate and c. Acute Cholangitis
comprehensive treatment plan d. Acute choledocholithiasis
Oxygen Therapy e. Acute Hepatitis A
ANTIBIOTICSfor CAP f. Liver Abscess
g. Alcoholic Liver Cirrhosis with
decompensation (worked as
PD 2: Presems sommelier)
Case 1
SHOW other PE findings
A 40 y/o female, single, food stall owner and Liver Span was 9cm. (+) tenderness on Right
used to work as a sommelier, presented to the Upper quadrant. (+) inspiratory arrest when
emergency room due to jaundice. gallbladder came in contact with the
She claimed she had feeling of bloatedness examiner’s hand.
before especially eating fatty meals but did not
seek any consult and started to go on diet. 3. Most likely Diagnosis of the case. (20
She was happy to lose about 10kg because of points) Acute Cholecystitis
her new lifestyle and diet and gained
confidence for her new look but noted 4. What are your recommended cost
intermittent right upper quadrant pain a week effective diagnostic Test? (20points)
ago. She also noted shoulder pain which she a. CBC (4points)
thought was just a sign of fatigue from b. SGPT, SGOT and Alkaline
cooking. phosphatase (4points)
c. Total bilirubins, B1 and B2 (4points)

1 scan = 1 prayer na magcclerk ako 1 retype = 1 prayer na magbabago ang cases sa PD


d. Ultrasound of the hepatobiliary tree d. Palpation of the gallbladder
(4points) (4points)
e. CT scan of whole abdomen e. Check for Murphy’s sign (4points)
(4points)
5. What are your recommended appropriate 2.What other focused PE will you do to
and comprehensive treatment? (20points) further assess the patient? (20 points)
a. Hydration ● Measure abdominal girth (2points)
b. Pain reliever: Meperidine or NSAID ● Percussion for general tympanism
c. IV antibiotics (5points)
d. Surgery: Lap Cholecystectomy with ● Palpation for tenderness and
Iintraoperative cholangiogram or Open especially for guarding or rebound
chole with IOC tenderness (8 points) CVA tenderness
e. ERCP with IOC (2 points)
Note: UDCA but does not work with ● Rectal Exam (3 points)
pigment stones (esp Asian)
3. Formulate differential diagnoses
Case 2 (20points) Give at least 5
A 40 y/o female. Single, lawyer, smoker, a. Peptic Ulcer Disease, Duodenal
diabetic, hypertensive presented to the Ulcer
emergency room due to abdominal pain. b. Peptic Ulcer Disease, Gastric Ulcer
She claimed she had been experiencing c. Acute Pancreatitis
burning or gnawing epigastric pain and was d. Acute Gastritis
already advised by her previous physician to e. Acute Myocardial Infarction
lessen stressful activities, stop smoking, f. Functional Dyspepsia
caffeine and alcoholic intake but her work as
lead prosecutor for several cases was so PE Findings:
demanding that she admitted she could not Epigastric Tenderness present. Rigid board
make these changes. like abdomen. Tarry stool on examining finger.
She noted intake of food would relieve the (-) CVA tenderness
pain in 2 hours before but five days ago, pain
continued even with intake of her previous 3. Most likely Diagnosis of the case. (20
medication aluminum hydroxide + magnesium points) Perforated Duodenal Ulcer with
hydroxide plus simethicone (Maalox) and Acute Peritonitis
omeprazole. She also noted radiation of pain
to the back. She felt nauseous and vomited 4. What are your recommended cost
previously ingested food also and noted pain effective diagnostic Test? (20points)
had increased intensity that she could no a. CBC and electrolytes (5points)
longer ambulate, hence, she was finally b. Amylase and Lipase (5points)
brought to the ER. c. Xray(Upright Chest Xray or
BP: 90/60 HR 120 RR 22 Temp 38.5° C BMI Abdominal Xray) for
26 Pale palpebral conjunctivae Pneumoperitoneum (5points)
Abdomen was round and without lesion. d. Ct scan with oral contrast (5points)
Absent bowel sounds.
5. What are your recommended appropriate
Show other and comprehensive treatment? (20points)
1. What other focused PE will you do to a. Hydration
further assess the patient? (20 points) b. NGT insertion to drain and bowel
a. Measure abdominal girth (4points) rest/NPO
b. Percussion for general tympanism c. Pain reliever
and also check liver span (4points) d. IV antibiotics
c. Palpation: especially for the Liver (4 e. IV PPI
points) f. Blood Transfusion

1 scan = 1 prayer na magcclerk ako 1 retype = 1 prayer na magbabago ang cases sa PD


g. Surgery: Emergency Exploratory
Laparotomy Abdomen is flat without noticeable lesions and
discoloration, normoactive, soft and non
SEMESTRALS PD 2: tender.

There is bilateral tenderness on striking the


Costovertebral angle.

2ND SEM PRELIMS: NEPHRO Pulses are equal, 2+ on all extremities. No


bipedal edema.
CASE 1
This is a case of a 33 year old female who
1. What else in the history would you like to
came in at the ER due to chills. Condition
ask the patient that would help you in
started 3 days prior to consult when the patient
narrowing her diagnosis?
started to complain of terminal dysuria
● Sexual history
associated with hesitancy and incomplete
● LMP, and if currently pregnant
voiding.
● Work: sex worker? Guest relation
2 days prior to consult, patient also noticed
officer?
“flushed” feeling, associated with headache,
● Personal hygiene
nausea and vomiting. Few hours prior to
● Use of birth control? Spermicides?
consult, patient complained of chills that
seems “not to go away”.
2. What are her differential diagnosis?
● Acute uncomplicated cystitis
Past Medical History:
● Acute pyelonephritis
Non diabetic, non hypertensive. Bronchial
● Sexually transmitted infection
Asthma, last attack last month, no controller.
● Nephrolithiasis
Family History:
● Pelvic Inflammatory Disease
Maternal history of Diabetes and
Hypertension.
3. Final Diagnosis (10 points)
Paternal history of Colon Cancer.
Acute (Uncomplicated) Pyelonephritis

ROS: Unremarkable.
4. What laboratory and ancillary test would
Physical Examination:
you request?
BP: 110/80 HR: 89 RR: 24 Temp: 38.9
● CBC platelet count
● Urinalysis
Patient is awake, ambulatory, conscious and
● Urine Culture and Sensitivity
coherent, acutely ill looking, not in
● KUB Ultrasound
cardiorespiratory distress.
5. Prescribe an antibiotic for the patient (10
Skin appears flushed, without noticeable
points)
localized lesions. No rashes.
● Antibiotics: any of these
○ Ciprofloxacin 500mg tablet
No cervical lymphadenopathy. Posterior
BID for 7days (or 1000mg
pharyngeal walls appears hyperemic but not
tablet OD for 7 days)
congested. Tonsils are not hyperemic and not
○ Levofloxacin 250mg OD for 7
enlarged.
days (or 750mg OD for 5
Chest expansion is symmetrical without use of
days)
accessory muscles of inspiration. Tactile
○ Ofloxacin 400mg BID for 14
remits are equal. Breath sounds are mostly
days
vesicular. No crackles, no egophony.
○ Cefixime 400mg OD for 14
days
Dynamic precordium, tachycardia with regular
rhythm. Good S1/S2, no murmurs noted.

1 scan = 1 prayer na magcclerk ako 1 retype = 1 prayer na magbabago ang cases sa PD


○ Ceftibuten 400mg OD for 14 Dynamic precordium, tachycardia with regular
days rhythm. Good S1/S2, no murmurs noted.
○ Cefuroxime 500mg BID for 14 Abdomen is flat without noticeable lesions and
days discoloration, normoactive, soft and non
○ Coamoxiclav 625mg TID for tender.
14 days No CVA tenderness noted.
6. Provide health education to the patient to Pulses are equal, 2+ on all extremities. No
prevent recurrence bipedal edema.
● Drink plenty of water
● Sexual hygiene (wash genitalia before 1. What else in the history would you like to
and after sex, urinate after sex) ask the patient that would help you in
● Don’t hold your urine narrowing her diagnosis?
● Wash your rectum daily and from front ● Sexual history
to back ● LMP, and if currently pregnant
● Proper perineal hygiene (do not use ● Work: sex worker? Guest relation
vinegar, or harsh soap) officer?
● Personal hygiene
CASE 2 ● Use of birth control? Spermicides?
This is a case of BB 19 year old female who
came to you due to hesitancy. Condition 2. What are her differential diagnosis?
started 2 days prior to consult when the patient ● Acute uncomplicated cystitis
started to notice incomplete voiding without ● Acute pyelonephritis
associated fever. 1 day prior to consult, patient ● Sexually transmitted infection
also experience hesitancy which prompted ● Nephrolithiasis
consult. ● Pelvic Inflammatory Disease
Past Medical History: 3. Final Diagnosis (10 points)
Non diabetic, non hypertensive. Acute (Uncomplicated) Cystitis
Bronchial Asthma, last attack last month, no
controller. 4. What empiric first line antibiotic would
you prescribe to this patient (10 points)
Family History:
Maternal history of Diabetes and First line antibiotics for AUC (any 1 of these)
Hypertension. ● Fosfomycin 3gram sachet single dose.
Paternal history of Colon Cancer. ● Nitrofurantoin 100mg tablet every 6
hours for 7 days
ROS: Unremarkable.
Physical Examination: 5. After 3 days, patient comes back to you
BP: 110/80 HR: 89 RR: 24 Temp: 36.9 complaining of persistent hesitancy
despite compliance with your prescribed
Patient is awake, ambulatory, conscious and medication. What would be your next
coherent, acutely ill looking, not in course of action?
cardiorespiratory distress. ● Request for a urine culture
Skin appears flushed, without noticeable ● Replace antibiotics with either a
localized lesions. No rashes. quinolone (levofloxacin, ciprofloxacin
No cervical lymphadenopathy. Posterior or ofloxacin) or beta lactams
pharyngeal walls appears (coamoxiclav, cephalosporin)
hyperemic but not congested. Tonsils are not
hyperemic and not enlarged. 6. Provide health education to the patient to
Chest expansion is symmetrical without use of prevent recurrence
accessory muscles of inspiration. Tactile ● Drink plenty of water
remits are equal. Breath sounds are mostly ● Sexual hygiene (wash genitalia before
vesicular. No crackles, no egophony. and after sex, urinate after sex)

1 scan = 1 prayer na magcclerk ako 1 retype = 1 prayer na magbabago ang cases sa PD


● Don’t hold your urine CVA Tenderness noted on the left. Pulses are
● Wash your rectum daily and from front equal, 2+ on all extremities. No bipedal
to back edema.
● Proper perineal hygiene (do not use
vinegar, or harsh soap) 1. What else in the history would you like to
ask the patient that would help you in
CASE 3 narrowing his diagnosis?
This is a case of CC 35 year old male who ● Intake of vitamins (excessive intake of
came in due to hematuria. Condition started 2 Vitamin C, Calcium)
weeks prior to consult when the patient started ● Previous diagnosis of Hyperuricemia,
to notice lower back pain more pronounced on Gout, Hyperparathyroidism
the left, without associated fever. ● Diet (high sugar, high protein, high
1 week prior to consult, patient also noted sodium diet)
initial dysuria with decreased force of urine ● Work and activities that may increase
however he claims that towards the end of water loss and promote dehydration
voiding, the dysuria and decrease force of (jeepney drivers, metro aide, traffic
urine would usually go away. Patient did not aides, athletes, etc)
sought consult and tried to self medicated with 2. What are your differential diagnosis
sambong capsule once a day without relief. ● Acute Complicated Pyelonephritis
1 day prior to consult, patient complained of ● Benign Prostatic Hyperplasia
blood tinged urine, which prompted consult. ● Prostate Carcinoma
● STI
Past Medical History: ● Non Gonococcal Urethritis
Non diabetic, non hypertensive. ● Prostatitis
● Epididymitis
Family History:
Maternal history of Diabetes and
Hypertension. 3. What is your most likely diagnosis?
Paternal history of Colon Cancer. Neprolithiasis, OR Urolithiasis
ROS: Unremarkable.
Physical Examination: 4. What laboratory tests, or ancillary
BP: 110/80 HR: 89 RR: 24 Temp: 36.9 procedure would you like to request?
● Urinalysis
Patient is awake, ambulatory, conscious and ● Flat plate of the abdomen, abdominal
coherent, acutely ill looking, not in XRAY.
cardiorespiratory distress. ● KUB Prostate UTZ
Skin appears not flushed, without noticeable ● IV Pyelography
localized lesions. No rashes. ● Non contrast Helical CTSCAN, CT
No cervical lymphadenopathy. Posterior Stonogram.
pharyngeal walls are non hyperemic, not
congested. Tonsils are not hyperemic and not 5. How would you manage this case
enlarged. (medical/surgical)?
Chest expansion is symmetrical without use of ● Analgesia (NSAIDS)
accessory muscles of inspiration. Tactile ● Alpha blockers (Tamsulosin, Alfuzosin)
remits are equal. Breath sounds are mostly ● Potassium Citrate
vesicular. No crackles, no egophony. ● ESWL
Dynamic precordium, tachycardia with regular ● Ureteroscopy
rhythm. Good S1/S2, no murmurs noted. ● Percutaneous Nephrolitotomy
Abdomen is flat without noticeable lesions and ● Nephrectomy
discoloration, normoactive, soft and non
tender. 6. How would you advise the patient?
● Increase oral fluids intake

1 scan = 1 prayer na magcclerk ako 1 retype = 1 prayer na magbabago ang cases sa PD


● Avoid dehydration Patient is awake, ambulatory, conscious and
● Eat less salt, including high sodium coherent, acutely ill looking, not in
foods like canned goods. cardiorespiratory distress.
● Limit intake high calcium foods like Skin appears flushed, without noticeable
cheese, milk, yogurt localized lesions. No rashes. No cervical
● Increase citrate in the diet, such as lymphadenopathy. Posterior pharyngeal walls
lemonade, oranges. appears hyperemic but not congested. Tonsils
● In uric acid stones, avoid foods high in are not hyperemic and not enlarged.
uric acid. Chest expansion is symmetrical without use of
● Avoid taking too much Vitamin C, accessory muscles of
Calcium and Vitamin D more than the inspiration. Tactile remits are equal. Breath
RDA. sounds are mostly vesicular. No crackles, no
● Limit how much protein you eat. egophony.
Choose lean meats. Dynamic precordium, tachycardia with regular
rhythm. Good S1/S2, no murmurs noted.
CASE 4 Abdomen is flat without noticeable lesions and
This is a case of a 55 year old male who came discoloration, normoactive, soft and non
in due to bipedal edema. Condition started 1 tender.
week PTC when the patient started to notice No CVA tenderness noted.
increasing blood pressure from baseline
120/80 to 180/100 mmHg associated with Pulses are equal, 2+ on all extremities.
headache and nape pain. Patient took Bipedal edema +2.
Amlodipine, 5mg tablet as advised by his Urinalysis Result:
friend. Color Amber to tea
3 days prior to consult, patient noted, frothy colored
urine, especially in the morning. pH 7.35
2 days prior to consult, patient also Specific Gravity 1.035
complained of bipedal edema starting at the Leukocytes 20-30/hpf
ankle but now has progress to mid-leg. This Red blood cell 30-40/hpf
prompted consult. Bacteria None
Epithelial Cells 10-20/hpf
Past Medical History: Glucose Negative
Non diabetic, non hypertensive. Protein (+) 4
Bronchial Asthma, last attack last month, no Ketones Negative
controller. Others RBC Cast (+)
Family History:
Maternal history of Diabetes and 1. Interpret the urinalysis
Hypertension. ● Abnormal color, or blood in the urine.
Paternal history of Colon Cancer. ● Concentrated urine
ROS: ● Sterile Pyuria
Weight gain >20% in the last week, Body ● Hematuria
malaise and fever 2 weeks ago. ● Massive proteinuria
(+)Hoarseness, (+) cough, (-) colds also 2
weeks ago. 2. What are your differential diagnosis?
(-) Difficulty of breathing. ● Acute complicated pyelonephritis
(-) Chest pain, (-) palpitations ● Urolithiasis, Nephrolithiasis
(-) Abdominal pain, (-) LBM ● BPH, Prostate Malignancy
Physical Examination: ● Nephrotic Syndrome
BP: 220/110 HR: 89 RR: 24 Temp: 36.9 ● Chronic Kidney Disease secondary to
Hypertensive Nephrosclerosis

3. Final Diagnosis

1 scan = 1 prayer na magcclerk ako 1 retype = 1 prayer na magbabago ang cases sa PD


Acute Post streptococcal
Glomerulonephritis (give 10 points), OR Laboratory studies:
Acute Glomerulonephritis (give 5 points).
CBC: normal
4. Aside from the Urinalysis, what labortary
test would you like to request? TSH: 23.0 [N: 0.4-4.0] FT4: 5 [N: 10-25]
● Complete blood count
● Serum Creatinine Serum cholesterol: 255 [N: <200]
● BUN
● Complement levels 1. What is the likely diagnosis? (10 points)
● Lipid profile, Cholesterol level ● Primary hypothyroidism
● ESR, ANA
● Serum Albumin 2. What are the most likely causes? (20
● Serum electrolytes (Potassium) points)
● Kidney ultrasound ● Autoimmune thyroid disease
● Kidney Biopsy (Hashimoto's thyroiditis)
● ● Radioactive iodine therapy for
5. How would you manage this patient? hyperthyroidism
● Anti hypertensive medications ● Thyroidectomy
(Preferably Alpha blocker, followed by ● External beam radiotherapy
vasodilator and calcium channel
blockers: like Clonidine, Hydralazine, 3. What additional aspects of the history
Nifedipine, Diltiazem) and physical examination could provide
● Loop Diuretics (Furosemide) relevant information to help in the
● Antibiotics (not for UTI) but for sore diagnosis? (20 points)
throat (Co amoxiclav, Cephalosporins, ● Family history or the presence in the
Quinolones) patient of other autoimmune endocrine
● Calcium supplements disease
6. What advice can you give to this patient? ● History of radioactive iodine therapy
● Eat less protein ● History of thyroidectomy, history of
● Limit salt and potassium in the diet neck radiation for lymphoma or head
● Limit fluid intake and neck cancer
● Monitor blood pressure regularly ● Symptoms suggestive of coronary
● Seek prompt consult for sore throat artery disease which would change
and skin infection therapy

2ND SEM MIDTERMS: THYROID 4. What additional tests would help confirm
the diagnosis? (10 points)
50 y/o housewife complains of progressive ● None. Thyroid autoantibodies are
weight gain of 20 pounds in one year, fatigue, arguably insensitive and the cost does
slight memory loss, slow speech, dry skin, not justify the benefit
constipation, cold intolerance.
5. What are the treatment options?
PE: Vital signs: BP: 140/100 ● Thyroid hormone replacement therapy
Pulse: 58/min, regular with levothyroxine
She is moderately obese and speaks slowly,
has a puffy face with pale, cool, dry, and thick 2ND SEM PRESEMS: MUSCULO
skin
A 35 year old male, no known comorbidity,
Thyroid gland: slightly enlarged, firm, not came in to your clinic due to left ankle pain.
nodular, mobile, and not tender deep tendon
reflex time is delayed

1 scan = 1 prayer na magcclerk ako 1 retype = 1 prayer na magbabago ang cases sa PD


Condition started few hours prior to consult,
when the patient woke up with severe ankle
pain aggravated with movement.

Increasing severity of pain prompted consult.


This one is considered to be chronic
1. Which questions would you like to ask
gout and is tophi (Dr. Antonio)
the patient to supplement your history of
present illness?

● History of preceding physical trauma/


strenuous activity?
● Intake of alcohol the night before?
● is there associated fever?
This is edema
Upon questioning the patient further, the
patient noted he did not have any history of
trauma, or strenuous activity in the last few
days.

There is no associated fever. However, has


drinking spree the night before. This on is the acute gouty attack

2. What in the Past Medical History would 4. Describe using your own words, the
you like to ask the patient? inspection and palpation findings in acute
● Congestive Heart Failure gouty attack?
● Psoriasis
● History of malignancy and recent Swelling (Tumor)
treatment/chemotherapy Tenderness (Dolor)
● Metabolic syndrome Warmth (Calor)
● Dyslipidemia Redness (Rubor)
Impaired mobility (loss of function)

Patient noted, he was diagnosed with


Psoriasis when he was 35, on remission.
No history of malignancy and congestive heart
failure.

3. Which among the following is the most


likely inspection findings of a patient
presenting with Acute Gouty Attack?

This one has redness


5. Using your own left foot, do the following
in order.
Dorsiflexion
Plantar flexion
Eversion
Inversion

1 scan = 1 prayer na magcclerk ako 1 retype = 1 prayer na magbabago ang cases sa PD


6. Please identify at least three medications
you should check with the patient that can
trigger gouty flares

Ethambutol - part of TB drug.


7. How would you manage this patient?
cause hyperuricemia by decreasing renal uric
● Ice compress 20 mins 4x a day
acid clearance.
● Colchicine 0.5 mg TID to QID
○ Oral tablet
Pyrazinamide - part of TB drugs
○ Alkaloid
is a strong urate retention agent, causing a
● NSAID/COX-2 Inhibitors
greater than 80% reduction in renal clearance
of uric acid
8. Provide at least two indication when to
start urate lowering therapy.
Aspirin - for vasodilation
● Recurrent arthritis / attacks >2
Can cause gout in low dose. aspirin actually
episodes
blocks reabsorption of uric acid by the kidneys,
● Presence of tophi
causing uric acid to be dumped out of the body
● Radiographic evidence of chronic gout
in the urine and lowering the blood level of uric
● Recurrent uric acid nephrolithiases
acid.is a strong urate retention agent, causing
a greater than 80% reduction in renal
clearance of uric acid

Diuretics - THIAZIDE diuretics


Diuretics can increase your risk of developing
gout, a type of arthritis caused by the buildup
of uric acid crystals in a joint. This may happen
because diuretics increase urination, which
reduces the amount of fluid in your body.
Thiazide diuretics are associated with elevated
serum uric acid (SUA) levels. They increase
direct urate reabsorption in the proximal renal
tubules

Levodopa - for patients with Parkinsons


Cyclosporine

1 scan = 1 prayer na magcclerk ako 1 retype = 1 prayer na magbabago ang cases sa PD

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