Diagnostic Techniques in Pathology 2014-5
ASSESSMENT 1: CLINICAL CASE STUDY
Instructions for the Case Study
Please use the following history, examination, and investigation images and results to complete parts 1-6 below.
History
Alfred Roberts is a 64 year old male who was admitted to hospital two weeks after reporting feeling unwell. The junior doctor who took his history reported that he
travelled abroad regularly on business, and recently had lost weight and experienced difficulty with breathing and difficult and painful urination.
Examination
On examination, Alfred was feverish with a productive cough. The same doctor performed a per-rectal examination and reported that his prostate gland appeared to be of
normal size. His basic observations were as follows:
(Day) temperature: 38.1?C
Blood pressure: 130/90 mmHg
Pulse rate: 100 bpm
Heart sounds: normal
Investigations
Biochemistry results:
Protein Result Normal Range High (?), normal (?) or low (?)
C-reactive protein 13mg/l
Creatine kinase 125 IU/l
Chest X-ray results
Figure 1. The chest X-ray pathology is indicated by the arrow.
Microbiology results:
A sputum sample was obtained and was noted to be purulent and blood-stained. The sputum sample was submitted for microscopy and culture.
Sputum Stain
Slides were prepared from Alfred’s sputum and then stained. The Gram stain gave an inconclusive result. However, microscopy showed the presence of rod-like bacteria.
Staining using Ziehl Neelsen’s method showed the presence of scanty acid-alcohol fast bacilli.
Pus cells: +++
Red blood cells: +++
Bacilli: +/-
Key:
– no cells seen
+/- 1-3 cells per field (scanty)
+ 4-10 cells per field (light)
++ 11-20 cells per field (moderate)
+++ >20 cells per field (heavy)
Sputum Culture:
The organism proved difficult to grow on all media, but was eventually grown on artificial media after 8 weeks had elapsed. The organism had the following antibiotic
resistance profile.
Ampicillin – sensitive
Isoniazid – sensitive
Urology
The patient was referred to an urologist, who requested that Alfred submit three early-morning specimens of urine to the laboratory. Significant results included 15
leukocytes per cubic mm., and 7 red blood cells per cubic mm. However, culture on CLED medium was negative.
Enzyme-linked immunosorbent assay (ELISA) Results
Commercially-available disease-associated antigens immobilised on the surface of plastic micro-wells specifically bound IgG antibodies to Alfred’s disease from his
serum. Peroxidase-conjugated goat anti-Human IgG bound Alfred’s IgG in the wells. Application of a substrate for peroxidase revealed a colour change (positive result).
What do you need to do?
(1) From your research of the history and examination (not the investigation results), produce a differential diagnosis (list of possible causes) of at least two
diseases. Explain how you reached your differential diagnosis. (300 words, 20 marks)
(2) Complete the table of the biochemistry results (100 words, 5 marks)
Give the normal ranges for the biochemistry results. Indicate whether Alfred’s results were high (?), normal (?) or low (?). Provide explanations for these results. Do
not add cells to the table.
(3) Choose and describe ONE pathology test which has been performed (300 words, 20 marks)
Make clear reference to the pre-analytical, analytical and post-analytical stages of processing. Make sure that this is a PATHOLOGY test i.e. would be performed by one
of the clinical disciplines in the pathology service.
(4) Interpretation of data (400 words, 25 marks)
Identify and explain the diagnosis of the patient with reference to the results of the investigations provided.
(5) Answer the following questions (400 words, 25 marks)
(a) Describe the lesion (abnormality) in the chest X-ray.
(b) Why did the urologist request the submission of three specimens?
(c) Why did the urologist specify early morning specimens?
(d) List which antibiotics might be used as treatments.
(e) Discuss the following issues regarding Alfred’s antibiotic treatment: route; combination therapy; drug resistance and length of therapy.
(f) Name and justify three further investigations you would order to determine the spread of the disease within the patient (i.e. not geographical spread).
(g) Describe the progress of the disease and the prognosis for the patient.
(6) Provide a list of references (not included in the word count, 5 marks)
Format according to the Harvard system.
CASE STUDY TOTAL: 1500 words, 100 marks
Your mark out of 100 will be scaled down to a mark out of 75 because the case study is worth 75% of the element mark.
Your Epigeum course is worth 25% of the element mark. You must pass the course; then the % mark on your certificate will be divided by 4 to give your mark out of 25%.
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