Recent Papers 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

Case 1

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
  • BP 120/70
  • Temp 38.1
  • Pale and dehydrated
  • Marked kyphosis
  • Crackles at base of left lung, decreased air entry

Parameter

Mr.C value

Hb

8.5g/dL

MCV

91fL

WCC

11.8 x 10 9 /L

Platelet

175 x 10 9 /L

WC diff

Normal

Blood film shows Rouleaux formation (see image below)

 

Biochemical investigations were also carried out and are shown below

Parameter

Mr. C value

Creatinine

222 µmol/L

Calcium

3.40mmol/L

Albumin

26g/L

Total Protein

98g/L

TASK

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?

Case 2

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

Parameter

Mr. L value

Temperature

37 oC

Pulse rate

85 /min

Resp rate

15 /min

Blood pressure

110/80

Blood work was requested and the key results are given in the table below.

Parameter

Mr. L value

Haemoglobin

9.2 g/dL

White Cell Count

9.2 x 10 9 /l

Platelet Count

290 x 10 9 /L

ESR

89mm/h

Serum Iron

6 µmol/L

Serum Ferritin

6 µg/L

Serum transferrin

<10%

Red cell folate

760ng/L

Serum vitamin B12

478 ng/L

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.

TASK

Prepare your case write up addressing the following questions. You are preparing this case for an audience largely made up of lay people

Questions:

  • 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?

Case 3

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.

Haematology results

Test

Miss F value

Hb

9.6 g/dL

White blood cell count

14.3 x 10 9 / L

Red blood cell count

3.0 x 10 12 / L

MCV

88fL

MCHC

33g/dL

Haematocrit

32%

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%
  • Lymphocytes 7%
  • Monocytes 5%
  • Eosinophils 4%
  • Basophils 1%

TASK

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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