Question

A 65-year-old man has chills, high spiking fevers, cough, and signs of consolidation in the left lower lobe of his lung. Blood is drawn for a CBC, sputum is collected for Gram stain and culture, and a chest X-ray film is obtained. Laboratory data are:

Hemoglobin: 14.5 g/dL

Hematocrit: 42%

Red cell indices: All within normal limits

White cell count: 24.0 ´ 109/L

White cell differential:

Segmented neutrophils: 33%

Band neutrophils: 61%

Lymphocytes: 6%

Platelet estimate: Normal with normal morphology

Sputum Gram stain: Many Gram-positive cocci in pairs; culture pending

Critical Thinking Questions

1. The patient appears to be suffering from a _____ infection. This type of infection is supported by _____ laboratory results.

2. The disease most likely exhibited by this patient is _______. This diagnosis is supported by _______ laboratory results.

CASE STUDY 12-1

A 45-year-old woman has severe liver disease with jaundice, purpura (bleeding into the tissues), and a platelet count of 120 ´ 109/L.

Critical Thinking Questions

1. What abnormality does purpura reflect?

2. Severe liver disease can influence the synthesis of which coagulation factors?

CASE STUDY 12-2

A 25-year-old man was admitted to the hospital for surgical repair of an abdominal hernia. He was in good physical condition, but his family history included minor bleeding problems among some of his male relatives. The following laboratory results are reported:

Prothrombin time: Normal

APTT: Prolonged

Factors VIII assay: Normal

Factors VIII:C: Normal

Factors VIII:vWF: Normal

Factor IX assay: Decreased

Platelet count: Normal

Platelet aggregation test: Normal

Critical Thinking Questions

1. Describe the genetic inheritance of various familial bleeding disorders.

2. Based on the history and laboratory results, what bleeding disorder might this patient have?

CASE STUDY 14-1

A 14-year-old high school student with fever, chills, and severe headache is seen in an urgent care clinic. He felt nauseated and vomited before reporting to the clinic. At the clinic, his temperature is 104°F; he has neck rigidity and complains of back pain. Some small petechial spots are noted on his chest and back and in the mouth. Blood is drawn for a complete blood count (CBC) and blood glucose, and lumbar puncture is performed. Cerebrospinal fluid (CSF) is collected sequentially in three sterile tubes and examined.

Blood Results

White cell count: 25 ´ 109/L

Differential: 80% neutrophils, 10% lymphocytes, 10% monocytes

Glucose: 95 mg/dL

CSF Results

CSF pressure: Increased

Gross appearance: All tubes equally cloudy, not bloody

Glucose: 15 mg/dL

CSF white cell count: 12.0 ´ 10⁹/L; 90% neutrophils

Gram stain: Many Gram-negative cocci in pairs, some intracellular

Critical Thinking Questions

1. Based on the Gram stain, what is the likely diagnosis for this patient? Explain the reason for your answer.

2. How can this patient’s diagnosis be differentiated from other similar clinical presentations?

CASE STUDY 14-2

A 75-year-old woman has had a long history of joint pain in the large joints. She now has shoulder pain and a swollen, red knee joint. She has a slight fever and bilateral muscle weakness in the lower limbs. Blood is drawn for hematology; radiographs of her knee are taken; and arthrocentesis is performed on her knee.

Hematology Results

Hemoglobin: 11.9 g/dL

White cell count: 12.0 ´ 109/L

Radiographic Findings

Calcification in the cartilage and meniscus (chondrocalcinosis)

Synovial Fluid Findings

Appearance: Cloudy and watery

Microscopic examination: Many neutrophils; intracellular and extracellular crystals present, appearing as small, chunky rectangles that show weak birefringence and appear blue when parallel and yellow when perpendicular to the slow wave of vibration of compensated polarized light.

Critical Thinking Questions

1. Explain the pathophysiology (defect) that produces this patient’s diagnosis.

2. Does this patient’s diagnosis resemble any other metabolic defects?

Answer 1

12-1

1 Streptococcus pneumonia,  Sputum Gram stain

2.Pneumonia, WBC count (as In bacterial pneumonia, the white blood cell count is typically high,) and Sputum Gram stain result is also supporting this.