#7 Case Studies: Give your diagnosis
A 17-year-old man presents to your clinic complaining of shortness of breath when he plays baseball at school. He has to sit down for a few minutes to go back to play. He is frustrated and afraid of telling his parents so they do not allow him to play. He has no family history of asthma. On physical examination, he has no respiratory distress. His lungs are clear. His heart is normal. His post-exercise examination shows signs of temporary bronchospasm, which subsides without any intervention.
What is the best treatment for this patient condition?
- A- Stop exercise instantly
- B- Prednisone 40 mg tablet/daily
- C- 2 puffs of albuterol 5-10 minutes before exercise
- D- Allergy testing
A 20-year old female student represents with a 1-week history of nausea, vomiting and anorexia. She returned 2-weeks ago from a trip to Guatemala. On physical examination, her temperature was 100.3 F, clear chest and she has mild jaundice and a palpable tender liver. Her CBC was normal and her liver function tests are as follows: Serum total bilirubin 3.1 mg/dL. Serum aspartate aminotransferase 1100. Serum alanine aminotransferase 1900. Serum alkaline phosphatase 112.
What is the most likely lab test to confirm your diagnosis?
- A- IgM antibody to hepatitis A virus
- B- Antibody to hepatitis B surface antigen
- C- Antibody to hepatitis C virus
- D- DNA for Epstein-Burr virus
- E- Serum anti-mitochondrial antibodies
A 32 year-old man complains of fatigue, weakness, edema and acne for 6 months. He is 70-In tall and weighs 220 Lb. His blood pressure is 148/90 mmHg. He has central obesity, enlarged subclavicular fat pads and prominent abdominal striae. His lab tests are:
24-hour urine cortisol excretion is 288
- Serum cortisol level is 18 at 8:00 am after taking 1 mg of dexamethasone at bedtime and next day it was 18.9 after at 8:00 am after taking 8 mg of dexamethasone at bedtime.
Plasma ACTH level is 281
What is the most likely site of the disorder causing Cushing syndrome in this patient?
- A- Pituitary gland
- B- Hypothalamus
- C- Lungs
- D- Adrenal glands
- E- Pancreas
#1: This is a case of exercise-induced allergic reaction. It is avoided by albuterol inhalation as a prophylactic before exercise. Gradually increasing the intensity and duration, not stopping, exercise is helpful to improve these symptoms. Allergy testing is not recommended unless there is another unknown cause of allergy. Prednisone is used in the treatment of asthma, not in this case. The correct answer is C.
#2: This is a case of active hepatitis A virus. Serum IgM antibody is the only option that confirms this diagnosis.
The correct answer is A.
#3: ACTH should be undetectable after administration of dexamethasone in normal people or any pituitary or adrenal gland dysfunction. The only reason for elevation of ACTH in hundreds is ectopic ACTH syndrome. Small cell carcinoma of the lung (oat cell carcinoma) is the most common etiology for ectopic ACTH syndrome. The correct answer is C.