Internal Medicine Cases
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Hi! I’m Alireza Mohammadhosseini. M.D , Internal Medicine Resident in Tums, IKHC. Here I share my simple and important cases, come and share your ideas!
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This is the uptodate algorithm for heparin induced thrombocytopenia
Look at the 4T score;
Our patient gained 7 scores. So we stopped Enoxaparine, started Apixaban as a direct oral anticoagulant, and ordered anti-PF4 level which was positive for heparin induced thrombocytopenia.
The plt count started to rise immediately and the plt level 3 days after Apixaban start was 218000.
End of case 21
In which of the following situations you can NOT see thrombocytopenia with Thrombosis?
Doppler sonogram was ordered which reported acute DVT in distal and also Proximal veins of left leg.
The patient plt count prior to surgery was 278000!
Case number 21
A 45-year-old woman - known case of rectal adenocarcinoma - who had colorectal surgery 2 weeks ago came to the emergency ward with complaint of left leg pitting edema.
She acclaimed that she was on 40 mg sub cutaneous Enoxaparine daily. She had stable vital signs.
Her initial lab tests:
WBC 11000 / Hb 9.5 / Plt 86000
Cr 1.0 / ESR 50 / CRP 40 / INR 1.07 / PTT 25
Look at the uptodate algorithm for empirical antibiotic therapy for pyomyositis.
Our patient was immunocompromised (HCL) and also hypotensive; So triple therapy is preferred.
The patient went on orthopedic surgery as soon as possible.
End of case 21
His MRI showed severe pyomyositis in right leg. he bacame tachycard (130) and hypotensive (70/P). Orthopedic consultation was ordered. What is your preferred antibiotic regimen?
Although the primary lesion was on his left foot and debridement was done for him at the beginning of the admission, after a week he complained about right leg swelling that became extremely severe within 48 hours. On examination of his right leg, a wide area with erythema, swelling and severe tenderness was observed.
+1A 36 cm spleen took our attention!
Peripheral blood smear showed special cells and bone marrow biopsy was positive for Hairycell leukemia
Look at the differential diagnosis for huge splenomegaly based on Harrison 2022 👇🏻👇🏻👇🏻
Case number 20
A 57 y/o man without any past medical history came to the emergency ward with the chief complaint of a necrotic supporative 2×2 cm wound in the lateral compartment of left thigh that was because of trauma to the wall and started to form from 2 months ago and did not heal over time.
CBC :
WBC 2200
Hb 7.6
Plt 12000
A single cut from his Abdominal CT scan is shown 👆🏻👆🏻👆🏻
As you can see in the algorithm for chronic diarrhea, basic lab tests were sent. Colonoscopy showed no specific pathology.
In lab tests leukopenia (WBC 2200) and anemia (Hb 9.6) took our attention.
Because of leukopenia, chronic diarrhea, oral candidiasis and weight loss and bitemporal atrophy, HIV infection was one of the most important diagnoses; and unfortunately HIV Ab test was positive for two times.
Note that despite acute diarrhea, chronic diarrhea is usually NOT due to bacterial infection and rarely needs antibiotics.
End of case 19
Case number 19
A 36-year-old health care worker man came to the clinic with the chief complaint of diarrhea from 2 months ago which is constant and not relieved with opioids (loperamide). He also complains about early satiety, significant weight loss (about 10 kg in 2 months) and odinophagia. On physical examination he has bitemporal atrophy and also oral white plaques in favor of candidiasis. His v/s was stable.
