Instituto de Ciencias y Estudios

Superiores de Tamaulipa, A.C.

CLINICAL CASE

Inglés

Isabel Cristina Romero

Martínez

Docente: Dra. Ana Lourdes

Garza Espinosa

8ºB
 CLINICAL CASE 1
History
A 43-year-old woman presents to her general practitioner (GP) complaining of
diplopia, more marked in the evenings, for the last 3 months. She has noticed
difficulty holding her head up, again especially in the evenings. She has problems
finishing a meal because of difficulty chewing. Her husband and friends have
noticed that her voice has become quieter. She has lost about 3 kg in weight in
the past 6 months. The woman has had no significant previous medical illnesses.
She lives with her husband and three children. She is a non-smoker and drinks
about 15 units of alcohol per week. She is taking no regular medication.

Examination
She looks well, and examination of the cardiovascular, respiratory and abdominal
systems is normal. Power in all muscle groups is grossly normal but seems to
decrease after testing a movement repetitively. Tone, coordination, reflexes and
sensation are normal. Bilateral ptosis is present and is exacerbated by prolonged
upward gaze. Pupillary reflexes, eyemovements and funduscopy are normal.

Questions
1. Which is the most probable diagnosis?
e. NSTE-ACS
2. Given the most possible diagnosis of NSTE-ACS, which initial
anticoagulation has the highest level of recommendation/level of
evidence in the recent ESC guidelines?
c. Fondaparinux
3. Which initial P2Y12 receptor antagonist should be chosen for this
woman with 48 kg?
e. Ticagrelor 2 x 90 mg
4. Regarding the antithrombotic strategy during PCI, which co-therapy
should not be chosen?
a. UFH (+ Abxicimab)
5. **How would you react to this bleeding complication?**
b. Switch to Prasugrel 10 mg
 CLINICAL CASE 1
Questions
What is the diagnosis and differential diagnosis?
1. Cervical ectropion
2. Vaginal infection (e.g., bacterial vaginosis, candidiasis)
3. Cervical polyps
4. Cervical or vaginal atrophy due to hormonal changes (e.g., menopause)
5. Cervical dysplasia or carcinoma (less likely given the absence of cervical
lesions and bleeding)

What is the diagnosis?

Based on the provided history and examination findings, the most likely diagnosis
is myasthenia gravis (MG).
 CLINICAL CASE 2
HPI: JH, a 16 year old girl you had as a patient since birth, has asked to see
you, she is concerned that she has not had any periods in the past six months.
She started memses when she was 13 and has always been irregular. She has a
boyfriend but denies any intercourse. She also denies breast tenderness,
galactorrea, nauea, or vomiting.

PMI: she attends a profesional ballet program during the day and takes
onlinehigh scholl courses at night. She has always been thin, but has lost
approximately 6 pounds since the profesional program began 8 months ago She
denies cigarette, alcohol, or drug use.

P/ E: Well appearing thing Young lady in on apparent distress. Vitals HR: 60; B
105/65 mm Hg, RR 14 afebril, Sa02 97% on room air.Head and neck
examination is unremarkable, including a normal thyroid gland. Chest exam
revels normal heart and the examination is unremarkable.

Questions
What is the likely disgnosis?
Based on the presented information, the likely diagnosis for JH is secondary
amenorrhea.

What is the difference between the primary and secondary forms of this
conditions? Explain it.
Primary amenorrhea refers to the absence of menstruation by age 15 without the
development of secondary sexual characteristics, or by age 13 with the absence
of secondary sexual characteristics. Secondary amenorrhea, on the other hand,
is the absence of menstruation for at least three cycles or six months in a woman
who has previously had regular menstrual cycles.

What are the possible causes of a primary and secondary form?

Possible causes of primary amenorrhea include congenital abnormalities (e.g.,
Mullerian agenesis), chromosomal abnormalities (e.g., Turner syndrome), and
hormonal disorders (e.g., polycystic ovary syndrome). Secondary amenorrhea can
be caused by factors such as pregnancy, hormonal imbalances (e.g., thyroid
disorders, pituitary disorders), extreme weight loss or low body fat percentage,
stress, and excessive exercise.
 CLINICAL CASE 2
Questions
What test would you conduct?
Tests that could be conducted include pregnancy testing, hormonal assays (e.g.,
thyroid function tests, prolactin levels), and imaging studies (e.g., pelvic
ultrasound).

What is the likely underling cause of her condition?

Given her history of significant weight loss and intense physical activity due to
her ballet program, the likely underlying cause of her secondary amenorrhea is
hypothalamic suppression due to low energy availability, known as functional
hypothalamic amenorrhea. This is a common cause of amenorrhea in athletes and
individuals with low body weight.
 CLINICAL CASE 3
HPI: PO is a 68-year-old Hispanic man who comes into your office for his annual
physical. He complains of intermittent lower back pain that is relatively new but
not concerning him much.
He denies any pain of difficulty with urination, although concedes his stream has
narrowed since his last physical exam last year.
PMI: PO is healthy and active in his community. He smoked as a young man, but
has not smoked for over 40 years. He eats a healthy diet ("my wife makes me!")
and drinks alcohol occasionally. He has had no previous hospitalizations or
surgeries.
P/E: PO is well-appearing and in no apparent
distress. Vitals: HR 85; BP 125/87 mm Hg; RR
16 afebrile; Sats 96% on room air. Percussion
of PO's back reveals moderate tenderness in
the low back, mid-line. Rectal examination
reveals a palpable mass on his prostate gland.
The remainder of the exam is normal.
Investigations: Serum prostate specific antigen
(PSA) is elevated at 160. You also order a
pelvic X-ray on this patient (see Figure 1).

Questions
What is likely the diagosis?
Based on the provided information, the likely diagnosis for PO is prostate cancer.

What would you include in the differential diagnosis and how would you
differentiate the two most likely conditions ?
Differential diagnoses may include benign prostatic hyperplasia (BPH) and
prostatitis. To differentiate between these conditions, further investigations
such as digital rectal examination (DRE), prostate-specific antigen (PSA) levels,
and imaging studies like pelvic ultrasound or MRI may be necessary. Prostate
cancer typically presents with an elevated PSA level and may have a palpable
mass on DRE, while BPH usually causes lower urinary tract symptoms without a
significant increase in PSA.
 CLINICAL CASE 3
Questions
What is the posible cause for his lower back pain?
The possible cause for his lower back pain could be related to metastasis from
prostate cancer, as the disease commonly spreads to the bones, including the
spine.

What conditions lead to elevation of PSA?

Conditions that lead to an elevation of PSA include prostate cancer, BPH,
prostatitis, and recent digital rectal examination or ejaculation.

What treatment is available for this condition?

Treatment options for prostate cancer depend on the stage and aggressiveness
of the disease. They may include active surveillance, surgery, radiation
therapy, hormone therapy, chemotherapy, or immunotherapy.

How this condition is related with benign prostatic hypertrophy?

Prostate cancer is not directly related to BPH, but both conditions can affect
the prostate gland. BPH is a non-cancerous enlargement of the prostate gland
that can cause urinary symptoms, while prostate cancer involves the abnormal
growth of prostate cells and can be malignant. However, both conditions can
cause elevation of PSA levels and may require similar diagnostic evaluations
such as DRE and PSA testing.
 CLINICAL CASE 4
A 30 year old woman presents to the emergency department with left lower
quadrant pain. She admits to being sexually active, but has an intrauterine
divice. A urinary human chorionic gonadotropin (hCG) test is positive, and an
ultrasound show a mass in the left fallopian tube. A section from the intratubal
mass is shown in the figure below.

Questions
What is your diagnosis?
Based on the presented information, the diagnosis is likely ectopic pregnancy,
specifically a tubal ectopic pregnancy.

What made you suspectof this condition?

The suspicion for ectopic pregnancy arises from the patient's symptoms of left
lower quadrant pain, positive urinary human chorionic gonadotropin (hCG) test
indicating pregnancy, and ultrasound showing a mass in the left fallopian tube.

What are the clinical implications?

Clinical implications of ectopic pregnancy include the risk of rupture of the
fallopian tube, leading to potentially life-threatening internal bleeding. Prompt
diagnosis and management are essential to prevent complications such as
hemorrhage and preserve fertility. Treatment options may include medical
management with methotrexate or surgical intervention, depending on the
severity of the condition and the patient's clinical status.
 CLINICAL CASE 5
A 33-year-old woman attends the infertility clinic with her 36-year-old partner
with whom she has been cohabiting for the last 10 years. She was on the
combined oral contraceptive pill (COCP) for the first 7 years of their relationship
but came off it 3 years ago as they wanted to start a family.
They have been trying unsuccessfully to conceive as the inability of a couple to
achieve conception after 12 months or more of regular (3-4 times per week),
unprotected sexual intercourse.
Eightyfive percent of couples in their twenties having regular sexual intercourse
and not using contraception will achieve conception within 12 months, although
this declines with increasing female age.
She started having periods at the age of 12 years and always had regular periods
with a cycle length of 28 days, which continued to be the case whilst on the
COCP.
She has never been pregnant. Since discontinuing the COCP 3 years ago, her
periods have been very infrequent with cycle length varying between 38 and 90
days.

Infertility can be classified as primary and secondary

When is consider a primary infertility?
La infertilidad primaria se considera cuando una pareja no ha podido concebir
después de al menos un año de relaciones sexuales regulares sin
anticonceptivos.

When is consider a secondary infertility?

La infertilidad secundaria se considera cuando una pareja que previamente
ha concebido de forma natural experimenta dificultades para concebir
nuevamente.

Questions
Discuss the causes of anovulatory infertility:
Anovulatory infertility refers to the inability to ovulate regularly, leading to
difficulties in conceiving. Causes of anovulatory infertility can include hormonal
imbalances, such as polycystic ovary syndrome (PCOS), thyroid disorders,
hypothalamic dysfunction, excessive exercise, low body weight or obesity, stress,
and certain medications. These factors can disrupt the normal hormonal signals
necessary for ovulation to occur regularly.
 CLINICAL CASE 5
Questions
What other aspects of the patient's history are relevant to establish the cause
of her anovulation?
To establish the cause of the patient's anovulation, other aspects of her
history that are relevant include:
- Any history of thyroid disorders or other hormonal imbalances
- Any symptoms of polycystic ovary syndrome (PCOS), such as irregular
periods, acne, hirsutism (excessive hair growth), or weight gain
- Any significant changes in weight or exercise habits
- Any medications she may be taking that could affect ovulation
- Any history of chronic stress or emotional factors that could impact
hormonal balance
- Any family history of infertility or reproductive disorders

By gathering detailed information about these aspects of the patient's history,

healthcare providers can better understand the underlying cause of her
anovulation and develop an appropriate treatment plan to help her conceive.