michelle craig case study

Diagnosis 1:

Admission diagnosis: Gastroenteritis with dehydration

Primary Complaint: Ten day history of nausea with vomiting, diarrhea, cough and congestion.

PATIENT HISTORY: Ms. Craig is a 24 yr. old white female with a 10-day history of viral syndrome. Her symptoms progressively worsened and she present to the ER. She was noted to have some petechial lesions of the lower extremities and appeared to be significantly dehydrated, and was admitted for further evaluation and treatment.

PROGRESS REPORTS:

1/28/94: Ms. Craig was admitted for treatment of gastroenteritis with dehydration as well as thrombocytopenia. Her initial treatment included administration of IV fluids, antiemetics and ciprofloxacin. She was transfused with 10 units of platelets, but this increased her platelet count only from 12,000 uL to 14,000 uL.

Treatment Plan:

Laboratory Tests Ordered: CBC, CMP, urinalysis, platelet count

1/29/94: A hematology consult was obtained. She was placed on IV Solu-Medrol. The follow up platelet count was 10,000 uL and she was given another 10 units of platelets.

Treatment Plan:

Laboratory Tests Ordered: Platelet count, iron profile, reticulocyte, sedimentation rate, hepatitis profile, urine culture.

1/30/94: The patient’s pulmonary congestion continued, and a chest X-ray revealed atypical pneumonia. She became hypoxic and was transferred to the transitional care unit for close hemodynamic monitoring. She was placed on supplemental oxygen and additional antibiotics. Though Ms. Craig had no symptoms consistent with lupus, the results of positive FANA (Fluorescent antinuclear antibodies), CRP and sedimentation rate warranted further consideration of this diagnosis.

Treatment Plan:

Laboratory Tests Ordered: Platelet count, rheumatology profile, CMP

Other Tests Ordered: Chest x-ray, echocardiogram, CT of abdomen

1/31/94: Twenty units of platelets were transfused.

Treatment Plan:

Laboratory Tests Ordered: Platelet count

2/1/94: A rheumatology consult was obtained, and as a result Ms. Craig received pulse doses of steroids. Ten units of platelets were transfused.

Treatment Plan:

Laboratory Tests Ordered: CBC, Antinuclear Antibody Profile

2/2/94: Consulting Physician’s Report:

Positive antinuclear antibody test with titer greater than 1:320 with a speckled and rim pattern. Positive anti-double stranded DNA. Mild decrease in complement and increased titers to anti-Sm and anti RNP.

Ms. Craig demonstrated and excellent response to the steroid treatment and her platelet count rose to 62,000 uL.

Treatment Plan:

Laboratory Tests Ordered: Platelet count

2/4/94: Ms. Craig was transferred to the regular floor on February 4, and she converted to oral prednisone.

Treatment Plan:

Laboratory Tests Ordered: Platelet count, CMP, sedimentation rate

Other Tests Ordered: Chest X-ray

2/6/94: Ms. Craig’s activity level and appetite were increased on February 6 and her platelet counts and CBC were stable. Ms. Craig was discharged with instructions to follow a regular diet, resume activities as tolerated and follow up with her primary care physician in 1 week.

Treatment Plan:

Laboratory Tests Ordered: CBC

Discharge Medications: Prednisone, Biaxin

Discharge Diagnosis: Thrombocytopenia, Systemic Lupus Erythematosis, Gastroenteritis with dehydration, Lupus vasculitis.

Learning Activities:

GOAL A: Relate laboratory data with Ms. Craig’s symptoms, history, diagnosis and prognosis on her admission to the hospital.

1. Identify relevant signs and symptoms, social and previous medical history and results of her physical examination.

2. Identify significant laboratory findings that are related to Ms. Craig’s clinical condition at the time of presentation. Correlate findings with her clinical presentation.

3. Review laboratory test results provided in the documentation and correlate this data with Ms. Craig’s diagnosis.

Study Questions Goal A:

1. Review the patient’s records and determine which of the presenting symptoms and which elements of the background history the physician may consider significant in her illness.

2. Identify the laboratory tests that were requested at the time of Ms. Craig’s admission. Which of the tests requested specifically correlate with her presenting symptoms? Highlight these tests.

3. Are there any laboratory test results outside the usual acceptable range? Identify those that are outside the usual acceptable range.

4. Are any of the values at critical levels? What do these results suggest? Do these results correlate with Ms. Craig’s presenting symptoms and how?

GOAL B: Evaluate the measures taken during the course of Ms. Craig’s illness and how these relate to her prognosis and outcome.

1. Interpret the data collected on Ms. Craig relating to treatment and prognosis.

2. Evaluate the use of the laboratory in this case.

Study Questions Goal B:

1. What are the most common causes of anemia?

2. What are the most common causes of thrombocytopenia?

3. Is Ms. Craig suspected of any of the conditions described in the above questions?

4. Describe the symptoms of Systemic Lupus Erythematosis and what led her physicians to investigate the possibility of SLE.

5. Why did Ms. Craig’s platelet count remain unchanged after her numerous platelet transfusions? Why did she respond to the steroid therapy?

6. What are complications for a patient with long term SLE and how should Ms. Craig be followed for progression of her disease?

7. Do any of her lab tests indicate kidney damage? How do you explain the increased BUN on admission?

8. Explain results of the C-reactive protein performed on 1/29 and the results of the ANA profile on 2/1.

9. Why was an iron profile ordered, what were her results and what does this indicate?

10. Are there any tests that have not been ordered on Ms. Craig that would be helpful in arriving at a more specific diagnosis? How appropriate were the lab tests that were ordered on Ms. Craig?

Diagnosis 2:

Initial Diagnosis: Gastroenteritis

Primary Complaint: Diarrhea and vomiting; urinary urgency and burning

Patient History: Patient has been doing well until this past weekend, when she began diarrhea and vomiting. She suspects that she has eaten contaminated food and comes to the physician’s office.

Progress Reports:

8/7/96: Patient was evaluated for routine laboratory tests and current status of her SLE. It was noted that she has 2+ pitting edema of the lower extremities. She was treated with Phenergan as need and a clear liquid diet and told to push fluids.

Treatment Plan:

Laboratory Tests Ordered: CBC, urinalysis, CMP, sedimentation rate, rheumatology profile, urine C&S.

8/8/96: Patient was called and asked to return to Physician’s office to follow up with a nephrology consult.

8/9/96: Patient was seen in the Nephrology office to assess renal function.

Treatment Plan:

Laboratory Tests Ordered: Creatinine clearance, urinalysis, 24-hr. protein

Other Tests: Renal biopsy

8/14/96: patient admitted to hospital for renal biopsy.

Results of Biopsy: The specimen consists of three pieces of pale tan tissue obtained from the right kidney. All glomeruli are involved and are membranous in appearance and proliferative with necrosis. Immunofluorescent stains are positive against IgA, IgG, C3, C4 and CIq. Fibrogen, albumin, and properdin are negative. The striking finding is the presence of deposits in the glomerular basement membrane in an intra membranous distribution as well as a subendothelial distribution. Inflammatory cells are also seen. These findings are consistent with lupus nephritis.

8/16/96: Patient tolerate the renal biopsy well and was placed on oral Cytoxan. The patient’s urinary tract infection was clearing and her nausea and vomiting had resolved. Patient will continue treatment on an outpatient basis and patient was discharged.

Treatment Plan:

Discharge Medications: Prednisone, Plaquenil, Cytoxan, Floxin, Phenergan

Discharge Diagnosis: Systemic Lupus Erythematosis, Nephritis secondary to Lupus, Urinary tract infection, Nausea and vomiting

Learning Activities:

GOAL A: Relate the laboratory data with patient’s symptoms, history, diagnosis and prognosis on the patient’s office visit.

1. Identify clinical symptoms that assisted the physician in assessing the patient’s condition.

2. Identify significant findings related to the patient’s condition during this admission.

3. Correlate laboratory data to the patient’s diagnoses.

Study Questions Goal A:

1. Determine which symptoms and which parts of the background history the physician may consider significant to the patient’s current illness.

2. What laboratory tests correlate with the patient’s presenting symptoms and are any of these outside of the normal acceptable range?

3. What do these results suggest?

4. As compared to January 1994 what is the status of the patient’s anemia?

GOAL B: Evaluate the measures taken during the course of the patient’s current illness and how these relate to the prognosis and outcome.

1. Interpret the lab data collected on Ms. Craig related to treatment and prognosis.

2. Evaluate the use of the laboratory in this case.

Study Questions Goal B:

1. Compared to 1994 what is the status of the patient’s SLE?

2. What test results indicate renal function abnormalities?

3. What is the significance of the creatinine clearance evaluation and how is this test performed and calculated?

4. What can be said about the calcium and phosphorous results?

Diagnosis 3:

Admission Diagnosis: SLE, Lupis nephritis

Primary Complaint: Weak, Shaky, no appetite, nausea

Patient History: Patient states the she has been feeling weak for about 1 week. She has had a cough, a mild post nasal drip and sweats. She is concerned that she is having a recurrence of her lupus. She has not been having arthralgias, skin rash, photosensitivity, mouth ulcers, hair loss or any other symptoms beyond those stated. She has had anemia associated with her lupus previously. She is having sensation of rapid heartbeats.

Treatment Plan:

Laboratory Tests Ordered: CMP, CBC, sedimentation rate, UA, CRP, rheumatology profile, ECG.

7/23/98: Assessment; review of lab reports.

Treatment Plan: Patient placed on antibiotics and advised to return for a 2 week checkup.

8/3/98: Patient returns with continuing symptoms and increasing nausea and fatigue. Review of testing for lupus indicates that this is not a flare up of lupus. Investigate other viral conditions. Recheck in 1 week.

Treatment Plan:

Laboratory Tests Ordered: CBC, UA, CMP, iron profile, thyroid profile, CMV, EBV, liver profile, hepatitis profile.

8/11/98: Patient returns to discuss laboratory findings of 8/3/98. No significant changes on CBC, UA and CMP. Begin treatment with Propylthiouracil (PTU), 50 mg QID. Check for thyroid antibodies.

Treatment Plan:

Laboratory Test Ordered: Thyroid stimulating immunoglobulins

8/26/98:

Follow up of Patient: Patient is feeling much better, more energy and less nausea. Lab results reflect a normalizing T4 but a worsening anemia. Continue PTU and treat anemia with iron and multivitamin supplements.

Treatment Plan:

Laboratory Tests Ordered: CBC, Thyroid profile

9/10/98:

Follow-up of Hyperthyroidism: Patient is better, lab results are normal. Continue medication as indicated.

Treatment Plan:

Laboratory Tests Ordered: Thyroid Profile, CBC

A period of approximately 16 months passes, during which time the patient remains euthyroid and slightly anemic.

1/28/00: Patient returns for an office visit and complains of fatigue. Laboratory results show abnormalities consistent with hyperthyroidism and a more severe anemia. Schedule appointment in 1 month to check condition.

Treatment Plan:

Laboratory Tests Ordered: CBC, thyroid profile

2/28/00: Patient has no additional complaints, but there is laboratory evidence of deteriorating anemia and increasing hyperthyroidism. Patient is told to discontinue PTU due to depression of the bone marrow.

Treatment Plan:

Laboratory Tests Ordered: CBC, Thyroid profile

Other Tests Ordered: Radioactive iodine (RAI) uptake.

3/13/00: Patient’s radioactive iodine uptake results indicate that she is a good candidate for RAI therapy.

Treatment Plan: Schedule RAI therapy 3/15/00

4/18/00: Patient returns for evaluation of thyroid status. States that she is feeling better and gaining some weight.

Treatment Plan:

Laboratory Tests Ordered: Thyroid Profile

6/14/00: patient returns for follow-up of thyroid status. Complains of being weak and easily fatigued.

Treatment Plan:

Laboratory Test Ordered: Thyroid profile, CBC

Place patient on Synthroid.

Learning Activities:

GOAL A: Relate laboratory data to patient’s history, symptoms, diagnosis and prognosis of office visits.

1. Identify clinical symptoms that aid the clinician in assessing the patient’s condition during her office visits.

2. 2. Identify significant lab findings that are related to the patient’s condition during follow-up visits.

3. Review test results and correlate data with patient’s prognosis.

Study Questions Goal A:

1. Review medical records and determine which symptoms and history are significant in the patient’s illness.

2. What laboratory tests correlate with the patient’s presenting symptoms and determine if any are outside normal acceptable ranges.

3. Which results indicate a renal problem and do these results correlate with the patient’s presenting symptpms?

4. Are the patient’s symptoms reflective of a thyroid problem? If so which one?

5. Which autoantibodies are commonly found in patient’s with Grave’s disease?

GOAL B: Evaluate measures taken during the course of the patient’s illness and how these measures relate to her prognosis and outcome.

1. Interpret data collected relating to treatment and prognosis.

2. Evaluate the use of the laboratory in this case.

Study Questions Goal B:

1. The patient was initially treated with medication to reduce production of thyroid hormones. When the medication complicated her anemia it was discontinued and radioactive iodine treatment was used. After 3 months the patient became hypothyroid. Is this a common occurrence?

2. Is there a common pathology that links the patient’s three diagnoses? If so what is it?

3. Were appropriate tests ordered on the patient in diagnosing her illness?