Professional Documents
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Case 3
Clinical data: The patient was a 28- year- old female. She was hospitalized because of a week of
palpitation,() accelerated breathing and low extremity puffiness, and a 3-days chilly and fever. The
patient had suffered palpitation, accelerated breathing after physical labor for two years. She neglected it
because it can recover if she had a rest. In the latest week, she took part in the physical labor in water
reservoir before admission, and she felt severe palpitation, accelerated breathing. She often coughed with
foam sputum while working and had an oliguria and a badly sleep. She had received 3 days therapy for
chilly, fever and cough with mucous sputum before admission.
History of past illness The patient had had pulmonary tuberculosis and arthrositis during childhood.
Physical examination: temperature 38.5 , heart rate 130 beats/minute, respire rate 36 /minute, blood
pressure 120/70 mmHg. The patient was normally developed and in her right senses. Her oral lip color
was cyanotic. She had a jugular varicosity. ()Her heart margin protruded toward left between
the third and fourth rib space. ()Her lungs were dullnessand fremitus vocalis()
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exaggerated at apex of heart. Diastolic heart rumbling murmur and lung diffuse dry and moist rales(
) were heard. The low edge of the liver could be clearly touched 4cm below right rib ( -
3cm)with median hard and tenderness.
Laboratory examination
Hemogram: RBC 3.0109/lL, Hb100gram/L, WBC 11109/L, neutrophil 75%, lymphocyte
20%,macrophage 5%, erythrosedimentation30mm/hour, anti-O-hemolysin 600Unit.
liver function test GTP glutamyl transpeptidase 60IU/L total protein 62.5gram/L, albumin
32gram/L, globulin20.5/L.
ElectrocardiographyMyocardium of left atrium strain() and fibrillation. ()
Barium meal perspective: left atrium presses esophagus.
X ray posterior-anterior film show that Left atrium and right ventricle are enlarged. The pulmonary
vascular markings are exaggerated, with scattered focal shadow lesions.
Course in hospitalpenicillin and streptomycin ()were given to control pulmonary inflammation.
And cardiant ()was given to retrieve congestive heart failure. The patients pathologic
condition improved. At the afternoon of ninth day in hospital, the patient got up and suddenly fall down,
convulsion, coma, though emergency treatment was taken immediately but ineffective, the patient was
died.
Autopsy
appearanceoral lip() and nail bed cyanosis
heart: observed by students.
Liver: observed by students.
Pulmonary: cross section is dark red, and pale red liquid flow out when was pressed. Multiple and yellow
lesions diffused on the section.
Brain: Thromboembolism ( )was seen in right middle cerebroartery and ischemic necrosis lesion on
right temporal lobe.
Kidney: congestion, each kidney weight 200 gram.
Lower extremitylight edema.
Abdominal cavityyellow clear liquid 300 ml.
Tonsil: enlarged to about 32cm(chronic tonsillitis)
Question:
(1) What disease of this case is? Please present your evidences of diagnosis.(
- )
(2) How this disease goes on?
(3) What is the reason of this patient death?
(4) What diseases should be differentiated while on the way of finding the correct diagnosis?
Cerebrospinal fluid
Item Value Normal value
pans test (+), (-) (qualitative test of protein)
WBC 2106/L < 0.01106 /L
amylaceum 1.79mmol/L 3.6-4.5mmol/L
protein 1.08g/L 0.15-0.45g/L
chloridate 110mmol/L 119-129mmol/L
Case 6
teaching aim
Clinic data A 36-year-old man, who was a long-distance coach driver, complained with fever, malaise,
headache, diarrhea and abdominal pain for several days. He was received in hospital. The doctor found
that he had a hyperpyrexia with relative bradycardia.
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History of past illness: no significant past medical history
Personal history: He had no travel history to a malarial endemic area, and not contact with soil water. He
consumed alcoholic beverages only for social intercourse and denied any recent binges. He did not take
any medication including antibiotics before admission and denied blood transfusions, promiscuity or
intravenous drug abuse.
Physical Examination: The patient shown fatigue appearance with mild dehydration. The temperature was
40 and continued for whole day, the pulse was 85 times per minute. There was tender firm
hepatomegaly with moderately enlarged soft spleen. some rose-rash appearing on his chest without
pruritusno evidence of encephalopathy was found. No lymphadenopathy was detected. Respiratory
examination was normal.
Laboratory test: Full blood count showed a borderline leucopenia - 4.8 109/L with 51% neutrophils and
44% lymphocytes. The platelet count was 175 109/L and never dropped significantly throughout his
hospital stay. The initial ESR was 35 mm/h and the CRP was elevated 96 mg/L. The liver biochemistry
showed normal albumin levels with elevation of AST and ALT which were 120 units/L and 240 units/L
respectively. The serum electrolytes and renal function were within normal limits.
Blood culture, urine culture, serology studies for viral hepatitis, leptospirosis and dengue were dispatched.
The leptospira microscopic agglutination test was equivocal and hepatitis serology was negative for
Hepatitis A, B and C.
Image examination: The ultrasound scan of the abdomen showed an enlarged liver at 17.5 cm with a
coarse echo pattern. The intra and extra-hepatic bile ducts were not dilated, no calculi was visualized.
There was splenomegaly at 15.5 cm. The patient refused to give consent for a percutaneous liver biopsy.
Therapy: he was empirically treated with IV penicillin as leptospirosis was endemic in the region despite
the negative test.
Questions
1. Please make diagnosis for the patient depending on documents mentioned above.
2. How many diseases should be included in the differentiation diagnosis? Could you exclude these
diseases according to the data offered in the case?
Items
Date 17-9 22-9 24-9 Normal Chinese name
ALT 411 157 97 5-46 U/L alanine aminotransferase
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AST 409 61 29 8-46 U/L aspartate aminotransferase
GGT 204 159 123 5-54 U/L -glutamyltransferase-
TBA 43.69 0.06 0-10 umol/L total bile acid
TB 63.9 34.5 13.7 0-6 umol/L total bilirubin
UDB 19.3 8.8 5 0-6 umol/L direct bilirubin
IBI 44.6 25.7 8.7 1.7-17 umol/L indirect bilirubin
TPm 60 56.1 55.8 60-80 g/L total protein
ALB 38.4 31.4 31.3 35-55 g/L Albumin
GLB 21.7 24.7 24.5 20-35 g/L Globulin
A/G 1.77 1.27 1.28 1.09-2.5
Biopsy data:
Please observe the removed cholecyst and the slide from the operation carefully. Make some notes on
your notebook.
Question:
(1) Please make diagnosis for this patient depend upon both clinical and pathologic data.
(2) How does the calculus form in the cholecyst and bile commen duct?
(3) Has the patient had jaundice? Which kind of jaundice it is? How do you distinguish hepatic and
obstructive jaundice? It is better if you list the differentiating points in table form.
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system was not examined. Neural reflexes existed. Neck: Trachea was in midline, thyroid was diffusely
enlarged (), soft, mobile, nontender, but vascular murmur could be heard , regional node were not
palpable, fine tremor could be seen when she lifted evenly her hands.
Laboratory Data:
(1) Tests of Thyroid function:
Testing time Item value Unit normal Reference
2007.3.5. TSH 0.04 mIU/L 0.3-5.0
FT3 9.34 pmol/L 3.8-6
FT4 26.3 pmol/L 7.5-21.1
2007.7.23. TSH 0.07 mIU/L 0.3-5.0
FT3 4.92 pmol/L 3.8-6
FT4 6.87 pmol/L 7.5-21.1
TMAb* 37.5 % 0-15
TGAb* 71.7 % 0-30
TotT3 1.66 nmol/L 1.34-2.73
TotT4 89.35 nmol/L 78.38-157.4
RT3 0.49 nmol/L 0.46-1.05
*TMAb [][=thyroid microsomal antibody] TGAb [][=thyroglobulin antibody]
T3: Triiodothyronine T4: tetraiodothyronine RT3: Resin T3
(2) Blood routine: WBC 8.3109/L, MC 0.7109/L LC 3.4109/L, N:4.2109/LWBC%: LC40.9%,
MC: 9.6%N50%PLC303109/LMPV 9.4fLRBC 4.61012/L,HGB131g/L.
(3) Blood biochemistry: Normal. Stool and Urine routine: Normal.
EKGNormal.
X-ray: The heart and lung were normal.
Course in Hospitalization: The patient accepted the resection of most of thyroid on August 18, 2007.
What was seen in operation: Bilateral thyroids diffuse enlarge to the medial margin of sternocleidomastoid
muscle but not press the trachea, moderate hardness. Regional nodes were not palpated. After operation
her symptoms abated. She stopped taking the drug and was discharged on 8-24-2007.
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TSH 1.13 mIU/L 0.3-5.0
FT3 4.59 pmol/L 3.8-6
FT4 11.05 pmol/L 7.5-21.1
TMAb 2.9 % 0-15
TGAb 4.5 % 0-30
TotT3 1.88 nmol/L 1.34-2.73
TotT4 109.95 nmol/L 78.38-157.4
RT3 0.8 nmol/L 0.46-1.05
(2) Blood routine: WBC number: total WBC 6.410 9/L, among that LC 2.310 9/L, MC 0.4 109/L, N
3.7 109/L; WBC percent: LC 35.6%, MC:6.6%, N 57.8% ; RBC 5.2310 12 /L HGB 151g/LPLT
238109/L.
(3) Blood biochemistry: Normal. Urine routine and stool routine: Normal.
(4) Inspection of Pathogens: HBsAg-, HBsAb+, HBeAg-, HBeAb+, HBcAb-, HCAb-, HIV-,
SyphilisAb-.
EKG: Normal.
X-ray: The heart and lung were normal.
Color ultrasound check to thyroid: The thyroid enlarged asymmetrically, the right lobe of thyroid
enlarged more significantly. The size of the right lobe was about 523629mm, while the size of the left
lobe was about 441617mm. The thickness of isthmus of thyroid is about 4mm.The thyroid capsule was
smooth. Two solid hypoechoic nodules were seen in the left lobe of thyroid, their size were 8 7mm and
76mm respectively, the borders of these nodules were clear and regular. The echo in these nodules was
uneven. CDFI showed no abnormal color flow signal in the nodules. An oval-shaped mixed mass was
seen in the right lobe of thyroid, the size of mass was about 3830mm with a clear border, the distribution
of echo in which was uneven, many strong points of echo can be seen on it. The echo from the part of
thyroid parenchyma out of those nodules was even.
Course in hospitalization: The patient underwent the resection of part of thyroid under general anesthesia
status on August 20, 2007. The part of resection of the right lobe of the thyroid was 5 3 2 cm 3, the left
was 1.3 1 0.5cm3. Surgical incision healed well after the operation. He was discharged on August 27,
2007.
Biopsy data:
Please carefully observe the excisional specimens from two patients respectively. Pay special attention
to the differences between two cases at both gross and histological morphology. Make some notes on your
notebook. That will be helpful in your diagnosis.
Questions:
1. According to clinical and laboratory data, the observation of surgical specimens, what are your diagnosis
for two patients? Please list the basis of diagnosis. Has there any clinical feature not supporting your
diagnosis in each case?
2. In the process of diagnosis, what diseases should be distinguished with?
Case 10
Clinical data: A male patient, 58 years old, worker, Hainan native. The patient had left dull ahce in the loin
without any obvious cause for 4 months. The pain did not radiate to anywhere. He had no nausea and
vomiting, no chills and fever, no frequent or urgent micturition. He is well conscious. His appetite, sleep,
stool and urine were normal. In other hospital, he was diagnosed by USG (ultrasound graphy): Left upper
ureter single stone/calculus; Right renal multiple stone. He was given ESWLextracorporeal shock-wave
lithotripsy treatment in other hospital, but there is no any stones discharged. He came to our hospital for
further treatment and was admitted in hospital on 18th, March, 2007.
Past history: the patient denied hypertension, diabetes, heart disease, hepatitis, tuberculosis but have
chronic gastric peptic ulcer.
Personal history: the patient born and live in hometown without long term leaving and contacting
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infective water.
Family history: No similar disease was found in his family.
Personal hobby: The patient consumed a packet of cigarettes and 100g alcohol daily.
Physical Examination T 36.8HR 80/minR 20/minBP 130/85mmHgThe patient was well
built and in conscious state with active position. His abdomen was flat and soft, no mass was palpated and
no shifting dullness was found by percussion. His liver and spleen could not be palpated No bulge was
observed over kidney area where no tender and sensitive to percussion were examined. The area of ureter
was normal and no tenderness. The area of bladder not expanded. His external genital organs, anal, spine
and extremities are normal. The nerve reflexes were normal.
Color ultrasonography Check to kidney: Left kidney was 18585mm with enlarged pelvic (about 78mm
in width)and cortex was very thin z(normal: 8mm), no strong echo was detected in kidney (normal kidney
size: 10-125-63.5cm). The upper part of the left ureter was enlarged, about 13mm in diameter (normal
4-5mm, nearly cannot be seen). A strong echo mass about 1710mm with shadow was detected at the site
far from 35mm of pelvis outlet. The right kidney was normal in shape and size (2150mm) with smooth
capsule. The cortex layer was 10mm, no obvious enlargement was observed in pelvis. many strong echo
masses were observed in upper, middle and lower renal calices with shadow, in which the biggest one was
96mm. The right ureter was not enlarged. The bladder wall was smooth and no feeling defect, no
abnormal echo mass was observed. Color Doppler showed that blood stream signals were rare in left
kidney while abundance and in branches shape in right kidney.
X ray check: shape
Plain film: Left kidney was obviously enlarged. A 1.5x1cm hyperdense shadow was observed at forth
lumber vertebrae in left side. No obvious lesion was observed in other ureter passage.
Excretory urogram: The photos of urinary system were taken after injection of contrast agent 15min
and 20min.The visualization of right kidney and ureter were good but left could not be seen. The bladder
was filled well without any filling defect sign.
Chest film: The aorta was tortuous. The heart and lungs were normal.
Laboratory finding:
Blood routine: WBC number: total WBC 6.210 9 /L lymphocyte 2.2109 /L intermedial cell
0.8109 /L neutrophile 3.2109 /L. WBC percent: lymphocyte 36.01% intermedial cell
12.2% N51.7% RBC 5.111012/L HGB161g/L, PLT210109/L; HCT(hematocrit) 48.6%,
MCV(mean cell volume)95.3fL, MCH(mean corpuscular hemoglobin)31.5pg/.
Stool routine: normal. Urine routine: yellow, clear, WBC-, Glu-, specific gravity=1.030.
Inspection of pathogens : HBsAg +HbsAb -HBeAg -HBeAb + HBcAb +HCAb - HIV
-Syphilis Ab -.
Blood biochemistry:
Item Value Unit Normal parameter Chinese item
K 4.81 mmol/L 3.5-5.4 potassium
Na 142.4 mmol/L 135-148 natrium
Cl 102 mmol/L 96-106 chloride
Ca 2.35 mmol/L 2.2-2.8 calcium
BuNm 6.3 mmol/L 1.78-7.14 Urea nitrogen
CO2CP 26.9 mmol/L 22-27 carbon dioxide combining power
CREm 107.1 umol/L 44-133 creatinine
URIC 356 umol/L 90-420 acidum uricum
BUN/Cr 0.05 umol/L Urea nitrogen / creatinine /
Glu 4.6 mmol/L 3.89-6.11 Glucose
ALT 3.2 U/L 5-46 alanine aminotransferase
AST 26 U/L 8-46 aspartate aminotransferase
AST/ALT 0.81
GGT 26 U/L 5-54 -glutamyltransferase-
ALP 89 U/L 35-134 aspartate aminotransferase
UCHE 16016 IU/L 5400-13200 pseudocholine esterase
UTBA 0.1 umol 0-2 total bile acid
TPm 69.3 g/L 60-80 total protein
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ALBm 35.1 g/L 35-55 Albumin
GLB 34.2 g/L 20-35 Globulin
A/G 1.03 1.09-2.5
TB 17.6 Umol/L 1.7-20 total bilirubin
UDB 5.0 umol/L 0-6 direct bilirubin
lBI 12.6 umol/L 1.7-17 indirect bilirubin
PABI 247.35 mg/L 170-420 Prealbumin
AG 13.5 mmol/L 10-14 Anion gap
OSM 276.37 mosm 280-320 Osmole ,
Mmol: millimol(e) mosm: ['mzm] milliosmol
Umol: ['ju:ml] U: unit IU: international unit
Course in hospitalization: The patient received the left nephrectomy by posterior belly abdominoscope.
An incisional drainage tube was set. What was seen in operation: left kidney enlarged like a water sac
with 600ml hydrops, the renal parenchyma is very thin. The drainage tube was taken out on 23 th, March,
2007. The operative incision dermal sutures out was taken on 27th, March, 2007. Wound healing was
good. The patient was discharged on 29th, March, 2007.
Biopsy data:
Please observe the removed kidney and the slide from it carefully. Make some notes on your notebook.
Questions:
1. How did the renal calculi develop? Where dose (do) the renal calculi frequently occur?
2. What consequences can the renal calculi cause? Which among that occurred in this patient? (Clue:
please infer according what you see on the macro and micro biopsy specimen)
3. What diseases should be differentiated from renal calculi?
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