B4E2 - Study Cases
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1. Human Papillomavirus (HPV) : A 42-year-old woman presents to the physician's office for a routine gynecologic examination. She is feeling well and has no specific complaints at this visit. While reviewing your records, you see that she has not come in for a Papanicolaou (Pap) smear in approximately 5 years. She admits that she has not come in because she has been feeling fine and did not think it was really necessary. She has a history of 3 pregnancies resulting in three full-term vaginal deliveries of healthy children. She was treated at 22 years of age for Chlamydia infection. She has never had an abnormal Pap smear. Her social history is notable for a 1-pack per day smoking history for the past 25 years. She is divorced from her first husband and is sexually active with a live-in boyfriend for the past 3 years. She has had 7 sexual partners in her lifetime. Her examination today is normal. You perform a Pap smear as part of the examination. The report arrives 10 days later with the diagnosis of high-grade squamous intraepithelial lesion.
What is the most likely infectious etiology of this lesion?
2. No imaging indicated : A 45-year-old man with no significant past medical history presents with severe back pain after lifting heavy boxes at work 2 days ago. Other than his back pain, his review of symptoms is negative. His pain is exacerbated by coughing and sneezing. The pain radiates from his lower back down his right posterior thigh to his great toe when you perform both a straight leg raise and the contralateral leg raise tests. His strength, sensation, and reflexes are intact and symmetrical.
Which imaging modality would be indicated?
3. Chronic Kidney Disease (CKD) : A 46-year-old woman presents to the clinic for the first time, complaining of decreased urinary output with a foamy appearance for 5 months. She also complains of swelling in both legs and nonbloody, nonbilious emesis a few times a week. She was diagnosed with type 2 diabetes 10 years ago and has been taking insulin for 2 years. She does not check her sugar levels at home. When asked about her diet, she states that she eats the best she can for what she can afford but often has very little appetite and vomits sometimes. The patient last saw her health care provider 8 months ago, and insulin is her only medication.
On examination, the patient is an obese woman. Her temperature is 99 °F (37.2 °C), heart rate is 108 beats/min, blood pressure is 198/105 mm Hg, respirations are 19 breaths/min, and oxygen saturation is 94% on room air. She has periorbital edema. Her skin is hyperpigmented on both lower extremities. Her heart is tachycardic with an S4 gallop auscultated and without murmurs or rubs. When palpating the heart's point of maximal impulse (PMI), it is lateral to the left midclavicular line. There are vesicular breath sounds throughout both lungs. Her neck reveals no jugular venous B4E2 - Study Cases
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distension (JVD), and there are no carotid bruits. The lower extremities reveal pitting pretibial edema with a pit recovery time less than 40 seconds. Laboratory studies in your office include a urinalysis showing hyaline casts, 3+ proteinuria, and glucose, but negative for ketones. Her hemoglobin is 10.9 g/dL, and her hematocrit is 32% with a mean corpuscular volume (MCV) of 82.3 fL.
What is the most likely diagnosis?
4. Acute Kidney Injury (AKI) : A 54-year-old man with a history of type 2 dia-
betes mellitus and coronary artery disease is admitted to the coronary care unit with worsening angina and hypertension. His pain is controlled with intravenous nitroglycerin, and he is treated with aspirin, beta-blockers to lower his heart rate, and angiotensin-converting enzyme (ACE) inhibitors to lower his blood pressure. Cardiac enzymes are normal. He undergoes coronary angiography, which reveals no significant stenosis. By the next day, his urine output has diminished to 200 mL over 24 hours. Examination at that time reveals that he is afebrile with heart rate of 56 beats per minute (bpm) and blood pressure 109/65 mm Hg. His neck veins are flat, chest is clear, and heart rhythm is normal with an S4 gallop and no murmur or friction rub. His abdomen is soft without masses or bruits. He has no peripheral edema or rashes, with normal pulses in all extremities. His fundoscopic examination reveals dot hemorrhages and hard exudates. Current laboratory studies include Na 140 mEq/L, K 5.3 mEq/L, Cl 104 mEq/L, CO2 19 mEq/L, and blood urea nitrogen (BUN) 69 mg/dL. His creatinine (Cr) level has risen to 2.9 mg/dL from 1.6 mg/dL on admission.
What is the patient's new clinical problem?
5. Urinary Tract Infection : An 84-year-old woman is brought to the emergency department by ambulance from her long-term care facility for increased confusion, combativeness, and fever. Her medical history is significant for Alzheimer disease and well-controlled hypertension. The patient is "confused" and combative with the staff, which, per her family, is not her baseline mental status. Her temperature is 100.5 °F, heart rate is 130 beats per minute (bpm), blood pressure is 76/32 mm Hg, respiratory rate is 24 breaths per minute, and oxygen saturation is 95% on room air. On examination, she is lethargic but agitated when disturbed, her neck veins are flat, her lung fields are clear, and her heart rhythm is regular and tachycardic without murmur or gallops. Abdominal examination is unremarkable, and her extremities are warm and pink.
After administration of 2 L of normal saline over 60 minutes, her blood pressure is 95/58 mm Hg. The initial laboratory work returns. Her white blood cell count (WBC) is 14,000/mm3, with 67% neutrophils, 3% bands, and 24% lymphocytes. Serum B4E2 - Study Cases
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lactate is 3 mmol/L. No other abnormalities are noted. A chest x-ray obtained in the emergency department is normal. Urinalysis shows 2+ leukocyte esterase, negative nitrites, and trace blood. Microscopy shows 20 to 50 white blood cells per high-power field, 0 to 3 red blood cells, and many bacteria.
What is the most likely diagnosis?
6. Stress Incontinence : A 48-year-old G3P3 woman is seen in the office with complaints of a 2-year history of loss of urine four to five times each day, typically occurring with coughing, sneezing, or lifting; she denies dysuria or the urge to void during these episodes. These events cause her embarrassment and interfere with her daily activities. The patient is otherwise in good health. A urine culture performed 1 month prior was negative. On examination, she is slightly obese. Her blood pres-
sure is 130/80 mm Hg, her heart rate is 80 beats per minute, and her temperature is 99 °F (37.2 °C). The breast examination is normal without masses. Her heart has a regular rate and rhythm without murmurs. The abdominal examination reveals no masses or tenderness. A midstream voided urinalysis is unremarkable.
What is the most likely diagnosis?
7. Urge incontinence : A 24-year-old nulliparous woman is being seen in the office for problems with "losing urine at inconvenient times." She states that has had difficulty with feeling like she needs to void all the time. She reports that at least 10 times a day, she has such an intense feeling of needing to void that she has to run to the bathroom within 10 to 15 seconds or she will lose her urine in her clothes. The patient states that she avoids drinking a lot of liquids during the day due to this problem. "My life is ruined because of this bladder problem," she explains. Physical examination reveals a well-supported bladder and no hypermobility of the urethra. The neurologic examination of the perineal and perianal area is normal. Multiple cultures and assays for urinary tract infections and urethritis have been performed over the years, and the culture results have been negative.
What is the most likely diagnosis?
8. Acute poststreptococcal glomerulonephritis (APSGN) : A 14-year-old boy presents with a 3-day complaint of "brown urine." He has been your patient since birth and has experienced no major illnesses or injuries. He is active in band and cross-country, and denies drug use or sexual activity. Two weeks ago, he had 2 days of fever and a sore throat, but he improved spontaneously and has been well since. His review of systems is remarkable only for his slightly puffy eyes, which he attributes to late-night studying for final examinations. On physical examination, he is afebrile, his blood pressure is 135/90 mm Hg, he is active and nontoxic in
