Question

Please answer all questions and parts.

A 50 year-old Hispanic female came into your 24-hr Emergency care clinic complaining of purpuric lesions on her left and right ankles. She stated that she was being treated for rheumatoid arthritis with leflunomide and steroids.

1.What is your initial differential diagnosis? Give at least three. 3 pts.

She has lived in Coastal Texas for eight years. She is not on blood thinners. She denies use of alcohol, tobacco, or illicit drugs. She has not gone to the beach or been on the water for over five weeks. She has not eaten raw seafood in the last four weeks. She denies any known drug allergies

2a. What conditions might you now exclude? 2 pts

b. Why can you exclude these? 2 pts

The patient had rhinorrhea and myalgia. She stated she had no sore throat, shortness of breath but a sporadic cough, felt no fever or chills, no nausea, vomiting or diarrhea, no abdominal pain, no leg swelling or pain in the extremities. Examination revealed a temperature of 38.1°C, heart rate 106 beats per min, BP 126/68 mm Hg, respiratory rate 16 breaths per min, and oxygen saturation of 98%. Lungs were clear on auscultation. Lymphocyte count was 700/microliter (normal 1000-4800).

3a. Do these findings allow exclusion of some of the differential diagnosis possibilities, and suggest some other possibilities? 2 pts

3b. What other tests would you perform? 2 pts

The patient was given nucleic acid amplification tests for COVID-19, influenza A, and respiratory syncytial virus—all were negative. She returned two days later, complaining of shortness of breath. Her oxygen saturation had decreased to 94% .

4. What possibilities must now be considered? List at least four. 4 pts.

Radiography of the chest revealed a 5 cm mass in the left lower lobe. A CT scan revealed ground-glass opacity, and some left hilar lymphadenopathy.

5. What conditions from question 4 should be included? 4 pts

Patient now had a temperature of 39oC, complained of a productive cough with green sputum, weakness, nausea and vomiting. The heart rate now increased to 115 beats per minute, BP was 138/85 mm Hg. Auscultation revealed crackles in the left lower lobe. Oxygen saturation dropped to 92% within the two hour wait in the emergency room.

6.a. What are the most likely conditions the patient could have? 2 pts

b. What is your diagnosis? 2pts

Answer 1

1-Initial differential diagnosis are:

-Thrombocytic purpura -Allergic purpura/drug associated purpura -Senile purpura(due to trauma) -vasculitis purpura. -Disseminated intravascukar coagulation

2 -a-I might now exclude allergic purpura/drug associated purpura,DIC,senile purpura

2-b-i have excluded allergic purpura/drug associated purpura as she neither allergic nor on any drugs, excluding senile purpura and DIC because she didn't get any trauma and on blood thinners respectively

3-a-The given findings exclude possibilities of thrombocytic purpura,vasculitis purpura,the other possibilities that can be now included are-Flu, Pneumonia,Chronic cough,Upper Respiratory Tract infections, Undernutrition, HIV/AIDS,Bronchitis,asthma

3-b-The other tests i would perform are Complete Blood picture, CT scan of lungs, kidney and liver tests,sputum test

4-With the given findings of shortness of breath, decreased oxygen saturation levels the possibilities are - Viral infection of lungs. - Pneumonia. - Asthma. -Bronchitis and Bronchiolitis -COPD. -Interstitial lung diseases

5-with the findings of CT scan, hilar lymhadenopathy possible findings are

-Pneumonia. -Bronchiolitis

6-a- From the above findings,crackles sound on auscultation and decreased saturation is seen both in Pneumonia and Bronchiolitis but green sputum is the most consistent presenting symptom of bacterial pneumonia

6-b-Diagnosis-Bronchial Pneumonia