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03-22-2022 Using the clinical background and the laboratory data provided up to now suggest some possible differential diagnoses for Mr. C and explain your reasoning.
Case Studies in Pathology
Compendium of Cases
For each case read through the scenario and results given and then work through the questions given under TASK
Mr. C is a 57 year old male and has attended the family doctor with severe rib pain. Yesterday he stumbled and fell whilst out walking. Despite taking some aspirin the pain was so severe he did not sleep well.
His wife attended the appointment and added that her husband had also been complaining of low back pain for the last few months. Mr. C is an engineer. He adds that he has also been feeling very fatigued and has difficulty staying awake in the evening sometimes.
Mr. C has been a patient with this GP for nearly 20 years; based on his recollections the doctor thought that Mr C seemed a little shorter in height than he remembered.
Further history of the patient was obtained:
Mr C is a smoker and has smoked around 10 cigarettes per day for most of his adult life. He tends to have one alcoholic drink each weekday and a little more at weekends.
His recent health has included two occasions in the 6 months where he was prescribed antibiotics to treat chest infections. This is the first time Mr C has suffered from chest problems.
The GP notes that Mr C does look pale.
He denies coughing blood, hoarseness or voice changes.
The doctor recommended X rays to investigate further but Mr C did not attend for these for a few weeks. By this time he was suffering from shortness of breath, nausea and a cough which exacerbated the rib pain and returned to his doctor.
At this subsequent visit the doctor then referred Mr C to A&E
Findings from examination
Pulse 118 bpm
Pale and dehydrated
Crackles at base of left lung, decreased air entry
11.8 x 10
175 x 10
Blood film shows Rouleaux formation (see image below)
Biochemical investigations were also carried out and are shown below
Mr. C value
Prepare your case write up addressing the following questions. You are preparing this case for an audience largely made up of junior doctors
Question 1. Using the clinical background and the laboratory data provided up to now suggest some possible differential diagnoses for Mr. C and explain your reasoning.
Now consider the following further information
The chest radiograph on Mr. C reveals evidence of left sided pneumonia, a fractured rib and multiple ‘lytic’ lesions in the humerus. The lumbar spine shows evidence of osteoporosis and collapse of some vertebrae.
Serum protein electrophoresis (SPE) gave the following pattern
Still in the same style continue your write up of the case addressing the following questions
Question 2 Explain how these further findings allow you to make a firmed diagnosis for Mr. C.
In particular explain the pathology relating to the following findings:
The SPE pattern
The haemoglobin level
The calcium level
Question 3. How should Mr. C be managed?
Mr L. is a 52 year old teacher. He has come to see his doctor as he is experiencing a long period of tiredness and fatigue; this has been going on for longer than 6 months. He is longer able to exercise as he becomes short of breath. He has previously considered himself quite fit with no history of cough, palpitations or chest pain. He also has some concern about weight loss as he has lost about 5kg in the last few months and feels he has lost his appetite.
He does has a history of abdominal discomfort and about 7 years ago had a diagnosis of irritable bowel syndrome. A colonoscopy at this time was normal. He is currently reporting a change in bowel habits with periods of constipation followed by loose bowel motions.
Examination: abdominal examination no tenderness, organomegaly or palpable masses
Absence of rectal bleeding or melena
Cardiovascular and respiratory examinations were normal
His vital signs are given below
Mr. L value
Blood work was requested and the key results are given in the table below.
Mr. L value
White Cell Count
9.2 x 10
290 x 10
Red cell folate
Serum vitamin B12
Blood biochemistry (Urea and Electrolytes) was normal
A colonoscopy was carried out and revealed an annular tumour mass around the wall of the sigmoid colon. The presence of two ulcers and a polyp are also noted close to the tumour mass.
Prepare your case write up addressing the following questions. You are preparing this case for an audience largely made up of lay people
Explain the possible causes for Mr. L’s presenting symptoms. Discuss the laboratory data explaining how you can use this to explain some of the symptoms of Mr. L.
Explain why Mr. L has developed anaemia.
Explain the significance of the polyps and ulcer noted on the colonoscopy
How could Mr. L be managed?
Miss. F. is a 36 year old Caucasian English woman. She has visited her doctor because she has been feeling generally unwell for a few days. Miss F has a history of periods of feeling ‘off colour’ over the last few years. Occasionally she has a bout of fever and suffers from joint pain especially in her lower legs. In the past she has taken standard analgesics to deal with this joint pain.
On examination there is evidence of some inflammation, splenomegaly and also evidence of some bacterial infection.
Miss F value
White blood cell count
14.3 x 10
9 / L
Red blood cell count
3.0 x 10
12 / L
A peripheral blood smear shows slight poikilocytosis with a few target cells. There are inclusions in some erythrocytes.
The white cell differential gives the following
Segmented Neutrophils 83%
Prepare your case write up addressing the following questions. You are preparing this case for an audience largely made up of biomedical laboratory scientists
Explain what specific blood disorder Miss F is suffering from. Use the clinical history and laboratory data given to show how you have arrived at this conclusion
Can you suggest further investigations that may be useful to confirm this diagnosis?
Discuss the pathological mechanisms specifically underlying Miss F’s blood disorder. Suggest some possible causes of this pathology based on the information given.
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