Case # 1

A 36 year old man seeks his physicians attention

because of severe right costo-vertebral angle pain
which is not relieved by NSAIDs. Because his
physician is on vacation and because of the severity of
his pain, he goes to the local ER seeking help.
When questioned, he describes a colicky type pain
which radiates down to his right groin. On the way to
the hospital he vomited twice.
Physical exam reveals an agitated man in severe
distress.. His face is flushed and he is unable to remain
quiet during the examination, frequently attempting to
change position.

Case # 1
Initial laboratory findings:

WBC
RBC
Differential
Urinalysis
Glucose
Sodium
Potassium
Phosphorous
Calcium

18,500
4.8
shift to the left
5 rbc/hpf
100
150
3.8
3.2
12.5

Case # 1
1. What is the cause of this mans pain?
2. From the laboratory tests given which
values are most significant?
3. What is your clinical diagnosis?

Case # 1
6. What are the causes of hypercalcemia?

Case # 1
4. What additional tests would you
order?

5. What is your primary diagnosis?

Case # 2
Six weeks ago this 51 year old woman experienced an episode of
upper respiratory infection from which she recovered.
More recently at the urging of her husband she consults with her
physician because of a progressive weight gain of 20 pounds,
increasing fatigue and a difficulty in concentration. At times she
finds it difficult to tolerate the cold Maine winter temperatures.
Physical exam reveals an obese woman in no acute distress. Her
skin is cool and dry, her hair coarse and brittle. There is some
puffiness of the skin beneath both infraocular areas.
BP 160/100. Palpation of the neck suggests an increase in the size
of her thyroid gland and it is described as slightly tender.
A picture of the patient is shown.

edema

Case # 2
Initial laboratory findings:

Hgb
13.5
RBC
4.2
Differential smear moderate lymphocytosis
Basic metabolic profile - normal

Case # 2
1.What is your primary diagnosis:
2. From the history, physical and laboratory
findings what is the first test you would order
in your initial evaluation of this patient?
3. What are the potential causes of this
condition?

Case # 3
This 39 year old woman has noted a gradual
increase in her weight over the past six months.
Associated with this has been an increase in her
lower back pain as well as some muscle
weakness.
Physical exam reveals a woman who exhibits
predominantly a central obesity with her
peripheral extremities remaining thin. Her skin
is dry and wrinkled with some slight hirsutism
of her upper lip and chin. Blood pressure is
165/90

Case # 3
Initial laboratory findings:

Hgb
15.0
RBC
3.96
WBC
8,000
Plasma glucose 200
Serum sodium 149
Serum potassium 1.8

N =70-110
N = 135-145
N = 3.5 5.0

Case # 3
1. What additional lab tests would order?
2. What is your primary diagnosis?
3. What are the potential causes of this
womans condition?

Case # 4
This 62 year old man has a past history of BPH. More recently he
has been seen by his physician over the past six months because of
persistant hypertension. (190/110). His original diagnosis was
essential hypertension. Despite continued treatment with betablockers and diuretics he has remained hypertensive. More
recently he has complained of severe episodic headaches during
attempts to urinate, some nocturia and a general weakening of the
musculature of his extremities.
Physical exam revealed a BP of 192/110 and some atrophy of the
muscles of his legs. Ophthalmoscopic exam shows no evidence of
papilledema.
A CAT scan of the abdomen suggests a possible mass in the right
adrenal gland.
The mass was resected and the microscopic slides are
representative of the lesion.

Case # 4
Initial laboratory findings:

Hgb
14.8
RBC
3.9
WBC
8,500
Serum sodium - normal
Serum potassium - normal

Case # 4
1. What is your differential diagnosis?
2. What additional tests would you
order?
3. Following a resection of the adrenal
mass what stain(s) would you order to
support your primary diagnosis?

Case # 4
Where might you find this tumor other
than in the adrenal medulla?

Case # 5
This 57 year old woman has noted progressive
weakness and easy fatigability. She also gives a
history of anorexia, weight loss and diarrhea.
More recently she has noticed increasing
difficulty in walking and an increased
pigmentation of her skin over sun exposed
areas.
Physical exam reveals a pre-chachetic
appearing woman whose blood pressure is
94/50. She appears pale and her eyes appear to
be shrunken in their sockets.

Case # 5
Initial laboratory findings

Hgb
RBC
WBC
Serum sodium
Serum potassium
Serum glucose

12.0
3.0
3,800
126 N=135-145
6.0 N= 3.5 5.0
60 N= 70-110

Case # 5
1. What is your differential diagnosis?
2. What additional laboratory tests would
you order?

Case #6
This 38 year old woman, the CEO of a major computer systems
company, states that she has not felt well for several months.
She has been unable to sleep at night because of her strong heart
beat and irregular pulse. She has lost 18 pounds over the past four
months and currently describes herself as a nervous wreck!
Physical exam reveals a thin woman in no acute distress although
she finds it difficult to remain calm during her interview and
exam. Her temperature is 99.8. There is some mild peri-orbital
edema and she tends to stare at her physican in a prominent
fashion. Palpation of her neck suggests bilateral enlargement of
her thyroid gland but no lymphadenopathy.

Case # 6
Initial laboratory findings:

Hgb
13.5
RBC
3.8
WBC
11,500
Basic metabolic profile = normal

Case # 6
1. What is your principal working diagnosis?
2. What additional laboratory tests would you
order?

Case # 7
This 46 year old man gives a history of
persistant hypertension (190/120) which
has failed to respond to appropriate
medications. Despite this he has
experienced little in the way of symptoms
except for increased muscle weakness,
excessive thirst and nocturia.

Case # 7
Initial laboratory findings:

Hgb
RBC
WBC
Serum sodium
Serum potassium
Plasma renin

14.0
4.2
11,000
157
3.0

decreased

What is the problem?

1. What is your differential diagnosis?

2. What additional tests would you order?
3. What is the most common cause of this
disease process

Case # 8
This 38 year old woman complains of
progressive anorexia, nausea, vomiting
and irritability. She more recently has
had a seizure the cause of which remains
unexplained.
Physical exam reveals some papilledema
A chest x-ray shows a mass in the right
upper lobe of the lung.

Case # 8
Initial laboratory findings:

Hgb
RBC
WBC
Serum sodium
Serum potassium
Plasma osmolality
Urine osmolality

14.2
3.9
14,000
110
3.5 Normal
210
increased

Case # 8
1. What is your interpretation of the
laboratory findings?
2. Based on the laboratory findings what is
your diagnosis?

Case # 9
This 23 year old girl is brought to the ER in a
semi-comatose state. Her mother states that
her daughter had the flu 5 days ago and
more recently has complained of increasing
thirst and frequent urination. There is also a
history of a ten pound weight loss in the past
month.
Physical exam reveals a dehydrated patient
with a peculiar odor to her breath.

Case # 9
Initial laboratory findings:

Hgb
RBC
WBC
Blood glucose
Urinanlysis

15.0
4.2
13,500
475
glucose stick positive
clinitest - positive

Case # 9
1. What is your primary diagnosis?
2. How do you explain her current physical
condition?

Case # 10
This 46 year old woman developed pain in her
left femur. A x-ray revealed a lytic lesion in the
distal femur .(slide # 1).
A chest x-ray and mammogram were normal.
Physical exam revealed no evidence of hepatosplenomegaly or lymphadenopathy.
There were no palpable masses in her breast.
The only physical finding was a small nodule in
the left lobe of her thyroid gland.

Case # 10
1. Would you order any additional tests?
2. With the information available what are
your major considerations concerning this
womans problem?
3. Does the type of metastases aid in
determining the underlying cause?
4. Of what significance is the mass in her
thyroid gland?