Case A

A 27 year old woman presented to the Emergency Department because of

progressively severe unilateral knee pain of 24 hours duration. She was triaged for
surgical evaluation. No preceding injury or unusual physical activity was identified.
Plain radiographs of the knees were unremarkable.

Over the next 12-18 hours, her condition worsened. She returned to The
Emergency Department for reassessment. At this juncture, she was triaged for
medicine evaluation. Further inquiry revealed the absence of nausea, vomiting,
diarrhea, bloody stool, swollen glands, photophobia or ocular irritation, but now
revealed a history of dysuria and purulent discharge (present for the past few
weeks; not reported during first check-up). Past medical and family histories were
noncontributory.
Diagnostic Examination

Bulge test on the left knee is positive. Arthrocentesis was performed. 10 mL of

synovial fluid was obtained in three tubes. Subsequent analyses were
performed on the sample.
During Pelvic examination, purulent Cervicovaginal discharge was noted and
obtained; gram stain revealed the presence of gram negative intracellular
diplococcci

Questions:
1. What is the significance of the Urethral discharge gram stain with regards to
the patients sign and symptoms?
2. What is the most likely diagnosis of the patient?
3. Why is a bulge test performed? Describe the proper procedure for
Arthrocentesis.
4. What is the workup for the diagnosis? What are expected findings in this
condition? Explain
5. How is Cervicovaginal discharge obtained?
6. What is the workup for the CervicoVaginal discharge in this case?
Case B

A 33 year old married man is diagnosed with having a varicocele at the

Urology/Andrology Department (Chief Complaint: Infertility).
Initial semenalysis results were as follows.

Volume 3 mL
All other macroscopic parameters Normal
Sperm Concentration 20 million sperm / mL
Sperm Motility Progressive Motility: 20%
Total Motility: 40%
Sperm Morphology (Routine) 5% normal

A varicocelectomy was performed to correct the condition. After a year, continued

infertility was observed. Both the man and his wife underwent fertility testing. The
wife was found to be normal, but semenalysis result of the man were as follows:

Volume 3 mL
All macroscopic parameters Normal
Sperm Concentration 25 million / mL
Sperm Motility Progressive Motility: 30%
Total Motility: 50%
Sperm Morphology (Routine) 20% Normal; Sperm agglutination
noted

1. What is a varicocele? Explain

2. What are the parameters in semenalysis? What are their normal values?
3. What results (comparing the first and second semenalysis results) are
significant in explain the continued infertility of the man?
4. What tests are used in the fertility workup (for both Males and Females) with
regards to sperm?
5. What tests should be used to confirm the diagnosis of infertility?
Case C

A 3 year old child presents with chronic, recurrent pancreatitis and frequent bouts of
bronchitis; during these attacks, she expectorates thick mucus. She also suffers from
frequent diarrhea characterized by yellow frothy stools which are foul smelling. The
doctor orders a sweat test and obtains an osmometry reading of 215 mmol/kg.

Questions:

1. Given the constellation of disease presentation, why would the doctor order a
sweat test?
2. What is the most likely condition of the patient? What are its signs and
symptoms? How is it inherited?
3. Explain the process for performing a sweat test.
a. Gibson and Cooke Pilocarpine Iontophoresis
b. Sweat osmometry
4. What is the workup for the patients diarrhea in this case?
5. What pulmonary complications are associated with Cystic fibrosis?
Case D
An 63-year old man was rushed to the emergency department after being seen lying
unconscious on his rented room by the house caretaker. The caretaker had no
information on how long he remained unconscious as the man was alone even at his
age. The only evidence seen in the room was a dent on the tiled floor and some spilt
rum.
Admission findings include:
37.4C, 221/105 mm Hg, unresponsive to various stimuli but with shallow
breathing pattern. Evidence of otorrhea noted by physician.
Three tubes were collected via lumbar tap. Among noted on the physical examination
were as follows:
Tube 1: slightly hazy, pale red
Tube 2: slightly hazy, pink
Tube 3: slightly hazy, pink
Table 1. Chemistry and Serology Findings
CSF Albumin 40 mg/dL
CSF Glucose 3.4 mmol/L
CSF Lactate 2.5 mmol/L
CSF Glutamine 37 mg/dL
Plasma Glucose 5.6 mmol/L
Plasma Albumin 3.8 g/dL
Table 2. Microbiology Findings
CSF Gram Stain No microorganisms seen
CSF Culture Did not perform

Table 3. Hematology and Cell Count Findings

Cell counts were performed with 15 WBCs and 4 RBCs counted using the entire 9 mm2
of an Improved Neubauer counting chamber.
A Wright-stained cytocentrifuged smear came up with the ff.:
Differential Count
Monocytes: 15%
Lymphocytes 68%
Neutrophils 17%
Additional Findings
Few bacteria (bacilli) seen
Rare siderophages seen
Guide Questions:
1. Calculate the CSF/Serum Albumin Index. Interpret.

2. Explain how these results indicate a traumatic tap, fresh hemorrhage, or old
hemorrhage. How long might have the patient been unconscious?

3. What are the cell counts of the patient?

4. Are there any discrepancies on the results above? If yes, what possible corrective
action must be done? If no, explain.

5. Explain briefly how the findings would account for the patient condition.

6. Suggest a diagnosis consistent with the laboratory results. What other tests, aside
from clinical laboratory tests, that may support your diagnosis?
Case E
A 28-year-old pregnant woman is seen by an obstetrician for the first time during her
2nd pregnancy. She thinks she is around 33 weeks gestation. She is from Philippines
and 3 months ago relocated to Canada with her husband and family. Her patient history
reveals that she has a 6-year old boy. According to her, the first delivery was relatively
normal and uncomplicated but records show that the infant was slightly overweight at
9lb; Her maternity records from the Philippines also revealed the following chemistry
results:

At 24 weeks gestation
Fasting Plasma Glucose 110 mg/dL
1 hour plasma glucose 192 mg/dL
2 hour plasma glucose 165 mg/dL
Urine dipstick: Glucose 3+
Ketones Negative

Routine prenatal blood work is performed. The mother is determined to be type O Rh-
negative and an antibody screen reveals the presence of an anti-Rh(D). Her antibody
titer is positive to a 1:32 dilution. Her husband is determined to be type A Rh-positive.
To assess and monitor the severity of the suspected hemolytic process taking place,
weekly amniocenteses are scheduled.

Amniotic Fluid Test Results

33 Weeks Gestation 34 Weeks Gestation 35 Weeks Gestation
A450: 0.200 A450: 0.245 Lecithin: 4.7 mg/dL
L/S ratio: 1.1 L/S ratio: 1.5 Sphingomyelin: 2.4 mg/dL
Amniostat-FLM: Negative Amniostat-FLM: Negative Amniostat-FLM: Low
positive
 From the obstetricians viewpoint, the
delivery was pushed through via a
caesarean section. The amniotic fluid that
was seen upon delivery was described to be
greenish in color. This was tested at the ER
lab for bilirubin and was found to be
positive. This was then sent to a reference
laboratory for testing for bilirubin and as
well as Apt test.

Reference Lab Results:

Bilirubin: 0.2 mg/dL
Apt Test: Pink supernatant after standing for 2 mins.

1. Calculate the A450 for the amniotic fluid obtained at 35 weeks gestation using the
image provided above.

2. Using the Liley graph, at what zone does the A450 value fall at 35 weeks?
3. What clinical implications accompany this result?
4. Using the values for lecithin and sphingomyelin provided at 35 weeks, calculate the
lecithin/sphingomyelin ratio. Compare the findings for each week and interpret if the
lungs are mature or immature.
5. What laboratory results are possibly affected by some other factors in your analysis?

6. What does the Apt test result indicate? Explain its clinical significance

7. Is there any discrepancy on your bilirubin findings? Provide possible sources of error
and preventive action to be placed as policy in testing for bilirubin.
Case F

Dodong presented himself to a barrio doctor after experiencing a series of nights of

troubled sleep due to bouts of heavy coughing, difficulty in breathing and sweating.
Doctor ordered chest radiography and AFB staining of his sputum. Chest radiography
revealed bilateral opacity while AFB smears of a mucopurulent sputum was at 2+.

He was advised to visit the nearest city hospital to seek for treatment. There, he was
immediately placed into an isolation room and immediately taken for thoracentesis. Fluid
taken was sent to the laboratory for testing. The following results were noted.

Appearance: Milky with green tinge and blood-streaked

Pleural fluid Cholesterol: 58 mg/dL
Serum total cholesterol: 145 mg/dL
Pleural fluid glucose: 58 mg/dL
Pleural fluid triglyceride: 48 mg/dL
Adenosine deaminase: 42 U/L
pH: 6.8
Whole blood hematocrit: 42%
Pleural fluid hematocrit: 14%

Differential
Lymphocytes: 65%
Macrophages: 15%
Neutrophils: 3%
Plasma cells: 17%
Mesothelial cells: Rare

1. Is the fluid an exudate or a transudate? Why?

2. Is the fluid a chylous or pseudochlyous effusion? Why?
3. Is there a hemothorax or a true hemorrhagic effusion? Why?
4. What do the chemical findings indicate in relation to the possible diagnosis? Explain
why do such findings exist.
5. What do the differential counts signify to confirm the possible diagnosis?
6. What other tests can be made to confirm the diagnosis?
7. What possible intervention and treatment must be done for the patient?