Interactive case report seminar Exam case reports

Case report I 19 year ald patient is admitted to the hospital complaining of the pain in the loins, left groin, edema of left lower limb. Physical examination: edema of left lower limb up to the groin, the skin is livid, edema in right lower limb is only at the perimalleolar region Case report I/1

Questions I What is the probable cause of the edema of LLL? What diagnostic procedures would you use to to prove or rule out this diagnosis? Case report I/2

Examination of the veins US of veins of LLL: without the signs of acute venous thrombosis. CT angiography of the veins in the abdomen and pelvis: Massive thrombus, in the region of v. c. i. with collateral blood flow reaching up to the area of porta hepatis. In the caudal direction, there is only minimal propagation to the right common iliac vein, however at the left side the left common iliac vein is completely blocked by the thrombus. Another thrombus in renal vein. Case report I/3

Laboratory results Na: 138 mmol/l [ ], K: 3,8 mmol/l [3,8..5,0], Cl: 103 mmol/l [ ], Albumine: 18,0 g/l [35,0..53,0], CB: 47,0 g/l [65,0..85,0] D-Dimers: 724 ug/l [0..190] Case report I/4

Questions II What could be the cause of the pathological lab results and what can be their pathophysiological/clinical consequences? What other test would you perform? Which laboratory results can be typical of the thrombosis? Does a patient has to have a thrombosis if this parameter is pathologically increased? What is the probability of the thrombosis if the parameter is normal (negative)? What are the risk factors for the venous thrombosis? Which are present in this patient and how would you further examine them? Case report I/5

Kazuistika I pro učitele Výsledky jsou celkem jasné, je tam hypalbuminémie, měli by provést vyšetření proteinurie k potvrzení nefrotické syndromu. Možno diskutovat jeho příčiny. Zároveň vede k hyperkoagulačnímu stavu. Diskutovat D-dimery. Pacient má navíc genetickou trombofilii (diskutovat), konkrétně Leidenskou mutaci. Kazuistika I – pro učitele

Case report II The patient has these values of acid base balance: pH = 7,1 p a CO 2 = 9,6 kPa (72 mm Hg) p a O 2 = 8,6 kPa BE = -12 Case report II/1

P CO 2 torr Base Excess mmol/l pH=7,1 pH=7,2 pH=7,3 pH=7,37 pH=7,43 pH=7,5 pH=7,6 Acute metabolic acidosis Acute metabolic alkalosis Acute respiratory alkalosis Acute respiraotory acidosis Compensated metabolic alkalosis Compensated metabolic acidosis Compensated respiratory alkalosis Compensated respiraotry acidosis Case report II/2

Questions 1) What is the acid base balance disturbance? 2) Which values correspond to respiratory and which to metabolic processes? 3) What can we tell about the patient’s respiration? What about the alveolar ventilaation and/or diffusion? 4) Lack of bases (negative BE) is typical of what disturbance? 5) What is probably the cause of negative BE in this patient? 6) What treatment would you suggest according to previous conclusions? Case report II/3

Kazuistika II – pro učitele Lze najít v nomogramu Kombinovaná Met a R acidóza Acidémie Hyperkapnie – porucha alveolární ventilace Hypoxémie – asi též z výše uvedeného Respirační insuficience II. typu Hypoxémie může způsobit laktátovou acidózu Diskutovat možné příčiny stavu, např. těžkou CHOPN. Porucha difuze či např. ARDS by vedly k hypoxémii/hypokapnii, ovšem může dojít k vyčerpání dýchacích svalů a následně též k poklesu alveolární ventilace. Léčebně kyslík, podpůrná ventilace Kazuistika II – pro učitele

Case report III 35 year old patient, 1 year after acute myocardial infarction, acutely feeling bad during the night and sleep, transfered to the hospital by ambulance, strong palpitation, vertigo, anxiety. BP 80/50 mm Hg. ECG. Case report III/1

Questions I What are the risk factors for coronary heart disease? What are probable reasons for the fact that this patient had AMI in young age? Case report III/2

Chart of the risk of coronary disease in next 10 years Case report III/3 Non smokers smokers MEN WOMEN

Coronary risk The risk of CHD is higher than in the chart in these patients with: familiar hyperlipidemia diabetes mellitus; in men the risk dubles, in women is even higher than double family history of premature cardiovascular disease low HDL concentration; i. e. lower than 1,0 mmol/l in men and 1,1 in women triglyceride concentration > 2,0 mmol/l Case report III/4

ECG Case report III/5

Questions II What is the probable cause of patient’s symptoms? What is the explanation for his hypotension? What is the pathology on ECG? Is there some possible relevance to the previous myocardial infarction? What test would you do? Case report III/6

Kazuistika III – pro učitele Mladý pacient má zřejmě závažné rizikové faktory, hyperlipidémii, je kuřák? Je diabetik? Je hypertonik? Nicméně AIM i po 30. roku věku se mohou objevit Jde o komorovou tachykardii, velmi slabou systolickou efektivitu myokardu, proto má hypotenzi, nízký srdeční výdej (zřejmě způsobuje točení hlavy). Pokud by byl dušný, mohlo by být městnání na plicích. Bolest by signalizovala možnost akutní koronární příhody. Doplnit např. kardiomarkery (CK-MB, troponin…) Po odeznění akutního stavu i další kardiologické vyšetření (echo…) Kazuistika III – pro učitele