Question 1

INTRODUCTION

HISTORY OF PRESENT ILLNESS

Theon is a 35-year-old man with a long history of asthma. He was referred today by his family physician,
1 month after his last asthma exacerbation. He says his initial testing and diagnosis took place about 10
years ago, but he does not have those records with him today. He finished a 10-day prednisolone course 10
days ago and is currently taking theophylline sustained release tabs 400 mg twice a day and using an inhaled
corticosteroid (ICS)/long-acting beta2-agonist (LABA) combination inhaler. Despite these medications,
Theon had 3 exacerbations of asthma in the past year that required oral steroids and antibiotics. He is
unhappy with his current level of symptoms. He is tired of having to miss work because of asthma
exacerbations that use up his sick time and disrupt his life. When questioned further, Theon acknowledges
that he dislikes taking pills and frequently does not carry his inhaler with him. He states that he misses
about 30% of his scheduled doses. He has been to see his PCP for medication refills, and for fairly frequent
exacerbations, but has had no special testing or adjustment of his asthma treatment regimen since his
original diagnosis.

Past medical history: Gastroesophageal reflux disease (GERD;) + 3 asthmatic exacerbations last year, all
treated with oral corticosteroids +/- antibiotics. Hospitalized out of town for bacterial pneumonia and
asthmatic exacerbation during his ski vacation 11 months ago. No intubation required and regrettably, no
hospital records available.

Review of Systems: Positive for frequent colds and dry cough. Denies nocturnal dyspnea. Was briefly
allergic to shell food in his childhood

Surgical history: Tonsils removed at age 9

Current medications: fluticasone 115 mcg/salmeterol 21 mcg, 1 INH twice daily, theophylline 400 mg
orally twice daily, esomeprazole 20 mg nightly

FAMILY AND SOCIAL HISTORY

Theon's parents are alive and in good health. His father has a history of eczema and his brother has allergic
rhinitis.

Theon has been a police constable for 10 years and enjoys his job, but finds that his respiratory symptoms
are interfering with his ability to chase criminals at work. Theon has never smoked and is a social drinker.

PHYSICAL EXAMINATION NOTES

GENERAL: Well-developed, well-nourished male in no acute distress

HEENT: PERRLA, EOMI, Allergic cobblestones noted on conjunctiva, dark circles under eyes, boggy
nasal turbinates bilaterally without sinus tenderness. Clear secretions noted in nasopharynx

NECK: No palpable nodes, thyroid normal to palpation, and pulses symmetric

CARDIAC: Regular rate and rhythm; normal S1S2 with no gallops, murmurs, or rubs

RESPIRATORY: Clear to percussion bronchial breath sounds, with polyphonic-expiratory wheezes

generally. No nasal flaring or use of accessory respiratory muscles

ABDOMEN: Soft, nontender, bowel sounds present, no hepatosplenomegaly

 NEURO: CN II-XII, sensory and motor all intact. DTRs 1+ symmetric

PSYCH: Oriented x 3. Normal affect, good eye contact.

SKIN: No rashes or lesions noted

EXTREMITIES: Normal pulses, no cyanosis, clubbing, or edema

THEON S.

Even when I take my medicines and use my inhaler, I still get short of breath and have too many "flare-
ups" that keep me home from work.

__Age: 35
__Gender: Male
__Weight: 72.60 kg
__Height: 180.3 cm
__BMI: 22.3
__ Allergies: None

CASE DESCRIPTION

Theon is a 35-year-old male police constable with asthma, who was referred from his primary care
physician (PCP) for a pulmonology consult. We have limited access to his previous records, treatment of
past-year exacerbations (treated at satellite clinic), and previous lab reports. Referral form indicates that
compliance with medications is an issue, as well as frequent attacks that cause this patient to miss work.
Asthma first developed at age 28; he gives no history of childhood chest troubles or allergic conditions.

PAST VISITS

DATE RR KG BMI

Today 18 72.60 22.3

Jul 20, 2017 20 76.20 23.4

TESTS

PAST TESTS

DATE TEST ACTION

Jul20, 2017 Complete Blood Count (CBC) VIEW

Jul 20, 2017 Pulmonary Function Tests VIEW

Jul 20, 2017 Pulse Oximetry - At Rest VIEW

Jul 20, 2017 Theophylline Level VIEW

DIAGNOSES
CONDITION HISTORY

DIAGNOSIS STARTDATE END DATE

Asthma Exacerbation, Moderate Jul20, 2017 Jul30, 2017

Rhinosinusitis (RS) Jul20, 2017 Jul30, 2017

Pneumonia, Bacterial Sep23, 2016 Oct08, 2016

Gastroesophageal Reflux Disease (GERD) Aug20, 2014 Continuing

Asthma Aug22, 2007 Continuing

ORDERS

MEDICATION HISTORY

MEDICATION START DATE END DATE

fluticasone-salmeterol Aug 20, 2012 Today

esomeprazole Aug 20, 2014 Today

theophylline Aug 20, 2014 Today

cephalexin Jul 20, 2017 Jul 30, 2017

prednisolone Jul 20, 2017 Jul 30, 2017

Case MS142-01

THEON S.

Even when I take my medicines and use my inhaler, I still get short of breath and have too many "flare-
ups" that keep me home from work.

Age: 35 Gender: Male Weight: 72.60 kg Height: 180.3 cm BMI: 22.3 Allergies: None

CASE DESCRIPTION

Theon is a 35-year-old male police constable with asthma, who was referred from his primary care
physician (PCP) for a pulmonology consult. We have limited access to his previous records, treatment of
past-year exacerbations (treated at satellite clinic), and previous lab reports. Referral form indicates that
compliance with medications is an issue, as well as frequent attacks that cause this patient to miss work.
Asthma first developed at age 28; he gives no history of childhood chest troubles or allergic conditions

PAST VISITS

DATE RR KG BMI

Today 18 72.60 22.3

Jul 20, 2017 20 76.20 23.4

TESTS

PAST TESTS

DATE TEST ACTION

Jul 20, 2017 Complete Blood Count (CBC) w/ Differential VIEW

Jul 20, 2017 Pulmonary Function Tests VIEW

Jul 20, 2017 Pulse Oximetry - At Rest VIEW

Jul 20, 2017 Theophylline Level VIEW

DIAGNOSES

CONDITION HISTORY

DIAGNOSIS START DATE END DATE

Asthma Exacerbation, Moderate Jul 20, 2017 Jul 30, 2017

Rhinosinusitis (RS) Jul 20, 2017 Jul 30, 2017

Pneumonia, Bacterial Sep 23, 2016 Oct 08, 2016

Gastroesophageal Reflux Disease (GERD) Aug 20, 2014 Continuing

Asthma Aug 22, 2007 Continuing

ORDERS

MEDICATION HISTORY

MEDICATION START DATE END DATE

fluticasone-salmeterol Aug 20, 2012 Today

esomeprazole Aug 20, 2014 Today

theophylline Aug 20, 2014 Today

cephalexin Jul 20, 2017 Jul 30, 2017

prednisolone Jul 20, 2017 Jul 30, 2017

Caso 2

Un hombre de 23 años de edad se presenta con malestar general, sudores nocturnos, pérdida de peso y fiebre intermitente que
data de una enfermedad similar a la gripe 3 meses antes. En el examen, tenía linfadenopatía bilateral cervical y axilar; las
glándulas tenían 2-5 cm de diámetro, eran firmes, gomosas, discretas y bastante móviles. Su hígado y bazo no tenían
visceromegalia.

Estudios mostró que su hemoglobina era baja (113 g /L) y el recuento de glóbulos blancos era normal (4,2 × 109 / L) pero su
velocidad de sedimentación globular (VES) se elevó a 78 mm / h; la película de sangre no mostró ninguna célula anormal. No
se observó agrandamiento de las glándulas hiliares en la radiografía de tórax. Se retiró un ganglio linfático cervical para la
histología. La arquitectura gruesa del nodo fue destruida; el tejido consistió en histiocitos, eosinófilos, linfocitos y células
gigantes conocidas como células de Reed-Sternberg. Estas grandes células binucleadas son características de la enfermedad
de Hodgkin.

El examen de médula ósea fue normal, aparte de una eosinofilia reactiva y una tomografía computarizada (CT-PET) que no
mostró afectación de otros ganglios linfáticos. Este paciente tenía la enfermedad de Hodgkin en estadio 2 porque, aunque
solo estaba involucrado el tejido linfoide por encima del diafragma, su VES era superior a 40 mm / h. En vista de sus
síntomas, el sufijo 'B' se agregó a la etapa, lo que sugiere un peor pronóstico asociado con síntomas sistémicos. Le dieron
quimioterapia citotóxica con ABVD.

Caso 3

Un joven de 25 años se presenta con una historia de 12 meses de prurito intenso que le provocó un rash en su pecho y
espalda. Las lesiones aparecieron repentinamente y duraron de 6-12 horas, reemplazadas por nuevas lesiones en otros sitios.
Las lesiones variaron en tamaño desde unos pequeños milímetros a varios centímetros. Ataques ocurrieron 2 o 3 veces cada
semana. Además, él tiene experiencias de 4 episodios de repentina inflamación de labios que tomó 48 horas en disminuir. Él
dice que parecía como si hubiera recibido un golpe. Él no fue consiente de algunos factores desencadenantes y no tiene
historia familiar o personal de atopia. Su salud en general fue excelente y no está tomando ninguna medicación. Al examen
físico, las lesiones consisten en: relieve, eritematoso, parches irregulares, algunos con centros blancos y fueron típicamente
urticarias. El resto del examen fue normal.

Laboratorios mostraron una hemoglobina y conteo de leucocitos normales, sin eosinofília. Sus niveles de inhibidores del
complemente C4 y C1 fueron normales, excluyendo angioedema hereditario.

La urticaria fue bastante bien controlada por un antihistamínico de acción larga (levocetirizina) pero él se mostró reacio a
tomar estas tabletas a largo plazo. Tres años después, sus lesiones urticarianas están todavía presentes, aunque menos
severas; su causa es desconocida.