Project 12.Solutions

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Valencia College *

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Apr 3, 2024

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PROJECT 12 - IMMUNOLOGY SOLUTIONS Task 12-1: Matching Term Definition 1. ___n _____ lymphoma a. An overactivity of the thyroid gland. 2. ___a _____ Graves disease b. A chronic autoimmune disorder that causes skin to harden and scar. 3. ___m _____ psoriasis c. A multisystem autoimmune disease characterized by achy joints; inflammation of the fibrous tissue surrounding the heart; unexplained rashes on the face, neck, or scalp; and other disorders. 4. ___g _____ HIV d. A form of vasculitis that affects primarily the lungs, kidneys, and upper respiratory tract. 5. ___l _____ rheumatoid arthritis e. A chronic autoimmune disease in which a person’s white blood cells attack their moisture-producing glands causing dry eyes, dry mouth, and other symptoms. 6. ___h _____ vasculitis f. An inflammatory disease of the nervous system that disrupts communication between the brain and other parts of the body by forming plaques on portions of the sheaths surrounding the neurons of the brain and spinal cord. 7. ___k _____ Hashimoto thyroiditis g. The virus that infects and destroys T cells, paving the 1

way for other infections and cancers to enter the body. 8. ___e _____ Sjögren syndrome h. A condition that involves inflammation in the blood vessels due to the immune system attacking those vessels by mistake. 9. ___d _____ Wegener granulomatosis i. Causes chronic inflammation of blood vessels throughout the body. 10. __b ______ scleroderma j. Blood vessels in the fingers become narrow, diminishing blood supply and causing fingers to become pale, waxy-white, or purple in cold temperatures 11. ___c _____ systemic lupus erythematosus k. A condition that occurs when antibodies attack the thyroid gland directly, leading to insufficient production of thyroid hormone. 12. ___f _____ multiple sclerosis l. An autoimmune disorder in which the immune system attacks and causes inflammation of the joints and surrounding tissues of the body. 13. ___j _____ Raynaud phenomenon m. An autoimmune condition featuring thickening of the skin with associated redness and scaling. 14. ___o _____ polyarthritis n. A general term for a group of cancers that originate in the lymphocytes. 15. ___i _____ Behçet disease o. Inflammation and soft tissue swelling of many joints at the same time. 2

Task 12-2: Spelling Choice 1. erythematosus 2. lymphocyte 3. thymus 4. rheumatoid 5. vermiform 6. lupus 7. hemolytic 8. antigen 9. antibody 10. immunoglobulin 11. autoimmune 12. pathogen 13. scleroderma 14. apheresis 15. anticardiolipin 16. neutropenia 17. complement 18. receptors 19. sclerodactyly 20. granulomatosis 3

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Task 12-3: Medical Word Building 1. immunology 2. tonsillectomy 3. cytology 4. myeloma 5. leukemia 6. adenitis 7. lymphoma 8. cytosis 9. lymphadenitis 10. splenectomy Task 12-4: Proofreading Exercises PROOFREADING EXERCISE 1 - ANSWER (Changes indicated in BOLD) CLINIC NOTE REASON FOR VISIT: SLE. INTERVAL HISTORY: This is a 29-year-old African American female with SLE who is here today for a scheduled followup visit. She was last seen here in the lupus clinic a month ago with worsening arthralgias and had received triamcinolone 100 mg injection. The patient states that she did feel improvement after the triamcinolone injection . However, she started with increase in both her knees and elbows since the last 2 to 3 days. She does state that her ankle pain has improved. However, she continues to have morning stiffness for about 10 to 15 minutes in the morning. She denies any ulcers or rashes. Her SLE was diagnosed 5 years ago and has been characterized by lymphadenopathy , arthralgias, arthritis, pleuritis, pericarditis, lupus anticoagulant and anti-double stranded DNA, anti-Smith, ANA with a titer of 1,280, low C4 , low C3, and a history of a miscarriage. 4

CURRENT MEDICATIONS: She is on Plaquenil 400 mg once per day. FINDINGS: On physical exam, the weight is 191.3, temperature 98.1, blood pressure 113/73, and pain is 10/10 . On physical examination of the skin, there is no rash. Head and neck exam reveals no ulcers and no thrush. Lungs demonstrate bilateral air entry. Heart sounds: S1, S2 are audible, regular rate and rhythm. Abdominal exam shows she is soft, nontender , and bowel sounds are present. On extremity exam, there is trace edema with nontender calves . A comprehensive musculoskeletal exam reveals tenderness in bilateral elbows and knees and also some warmth is noted in both the wrists. However, there are no signs of arthralgias. Neurologically she is nonfocal. ASSESSMENT: SLE. The patient does have significant arthralgias and a recently noted low C4 value. She has already received a triamcinolone injection of 100 mg 10 days back and she continues to have arthralgias. She will be started on prednisone 5 mg once per day and also she was advised to start naproxen 500 mg 2 times per day with food. She is not a candidate for methotrexate at this time because there are no obvious signs of synovitis . On the physician estimate of activity, she received a 1 under joints. PLAN: She will follow up as previously scheduled. We will add prednisone 5 mg once per day and naproxen 500 mg by mouth 2 times per day as advised . PROOFREADING EXERCISE 2 - ANSWER (Changes indicated in BOLD) CLINIC NOTE REASON FOR VISIT: SLE. HISTORY OF PRESENT ILLNESS: This 32-year-old Caucasian female comes in for routine followup. She mentions some morning stiffness that is not any worse from previous visits. She also has had 2 episodes of either lower back pain or hip pain in the last 7 months. Most recently was 2 weeks ago and it lasted about 2 weeks. This is slowly resolving. She did actually have a bilateral hip MRI which was completely negative, although a large ovarian cyst was seen and she is currently being treated with a NuvaRing for this. The patient has never had a DEXA scan done. She does mention that she was on prednisone in childhood for about 6 years for Crohn disease. We mentioned that this would be appropriate to have as a test for her to do , and we have given her an order to get this done at her next visit. MEDICATIONS: Plaquenil 400, naproxen 500 two times per day as needed, aspirin 81 mg, Lexapro 10, amitriptyline 10, Tylenol PM as needed. FINDINGS: On physical exam, the weight is 160 pounds, temperature 99.1 degrees F., blood pressure 121/65, pain 0/10. On physical examination of the skin, there is no rash or alopecia present. She does have some acne present and will be following up with a dermatologist. On HEENT, there are no oral or nasal ulcers and no thrush present. On chest exam, she is clear to 5

auscultation bilaterally. Cardiac exam reveals regular rate and rhythm without murmurs, rubs, or gallops. Abdominal exam shows she is soft, nontender, nondistended. On extremity exam, there is no clubbing, cyanosis or edema. On comprehensive musculoskeletal exam, she does have some arthralgias of her MCPs and knees. There is no synovitis present. Neurologically she is nonfocal. ASSESSMENT: 1. SLE with arthralgias. On the physician estimate of activity, she scores a 1 with a 1 for joints. 2. She does have some facial acne. She will follow up with a dermatologist. I do not think that it is related to any of her current medications. Her dermatologist certainly may try her on MetroGel or minocycline . 3. We do recommend a DEXA scan as she has never had one done and she was on chronic prednisone use in childhood. 4. She has had these episodes of lower back pain and questionable hip pain. At the next occurrence , we asked her to contact the office and we would consider medication such as Flexeril as a muscle relaxant to see if some of this is due to muscle spasm. PLAN: Follow up in 3 months. Task 12-5: Cloze Exercises Cloze Exercise 1: Clinic Note (FamMed2BOS - Report #66) SOLUTION: 1. paresthesias 2. patellar 3. rock 4. straight-leg raising 5. regimen Cloze Exercise 2: Clinic Note (FamMed1BOS - Report #23) SOLUTION: 1. flare 2. NSAIDs 6

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3. osteoporosis 4. naproxen 5. Cor: 6. peripheral 7. erythema 8. nodules 9. musculoskeletal 10. ESR Task 12-6: Transcription Exercises: Transcription Exercise 1: Discharge Summary (AEAdvanced Unit 4 - Dictation 8) DISCHARGE DIAGNOSES: 1. Tracheal stenosis. 2. Iatrogenic cushingoid syndrome. CONSULTATIONS: Cardiothoracic, I. M. Smith, MD. HISTORY OF PRESENT ILLNESS: The patient is a 27-year-old Hispanic female who was admitted for difficulty breathing which began 7 days prior to admission. She was seen in the emergency room several times prior to admission with similar complaints and was given breathing treatments, which seemed to help. On this admission, she was given several breathing treatments of aminophylline and Solu-Medrol boluses, which had no effect. PHYSICAL EXAMINATION: On examination, the patient was an afebrile, normotensive female with a normal physical examination other than poor to moderate air movement. She did have upper airway stridor and the inspiratory segment was greater than the expiratory segment. Bedside pulmonary function tests revealed an FEV of 1.31, 45% of expected, and an FEF which was 37% of expected. The pulse oximetry was 98%. The chest x-ray showed no abnormalities. PAST MEDICAL HISTORY: History of a suicide attempt with a tricyclic antidepressant overdose 5 weeks prior to this admission. At that time, the patient was intubated and had a TCA level of 1800. During her stay in the intensive care unit and while intubated, she was very violent and had multiple thrashing around episodes. The patient was placed on intravenous Solu-Medrol and given respiratory treatments. 7

HOSPITAL COURSE: She underwent an indirect laryngogram which showed no swelling or abnormalities of the vocal cord or lingual tonsils. The chest x-rays revealed some narrowing of the trachea 3 to 4 cm below the vocal cord. A CT scan of the chest on hospital day #4 revealed tracheal stenosis at the level of the clavicular head about 3 to 4 cm below the vocal cords. This area of stenosis extended about 3 cm. The surgery team was immediately involved and decisions were made regarding the patient's further care. Racemic epinephrine treatments and Solu-Medrol treatments were continued. Dr. Hart was consulted, and it was felt that the only available therapy was a resection of that segment of the trachea which was stenotic. The patient was continued for several days on upper respiratory treatments. The patient's breathing remained adequate while on oxygen supplementation. Tracheal resection was accomplished on the twelfth hospital day. At that time, the patient's chin was sutured to her chest in order to prevent her from extending her neck, and a brace was also applied. Her postoperative course was essentially uneventful. The patient remained on intravenous penicillin and clindamycin, and her intravenous Solu-Medrol was weaned slowly. During the course of this wean, she became somewhat cushingoid. She was transferred from the intensive care unit on postoperative day #2 and she continued to do very well, and had a normal recovery of swallowing function. On postoperative day #8, the sutures holding the chin to the chest were discontinued. The patient was watched over the course of that day and after 16 hours, she had no problems with breathing and remained afebrile. She was considered stable for discharge. DISPOSITION: The patient was discharged home in good condition. She was instructed not to extend her neck and to wear the brace at night to maintain neck flexion. She was told that the consequences of this may mean damaging the tracheal anastomosis and possibly death. FOLLOWUP: She was instructed to follow up in the clinic in 1 week. DISCHARGE MEDICATIONS: 1. Prednisone taper starting at 15 mg for 5 days and tapering to 5 mg for 5 days. 2. Nystatin cream to the monilial rash of the neck. 3. Tylenol No. 3. DISCHARGE INSTRUCTIONS: The patient was instructed to call if there are any problems and to come to the emergency room immediately if she has any difficulty breathing. Transcription Exercise 2: Operative Note (GenSurgBOS - Report #6) OPERATIVE NOTE PATIENT: John Jones OPERATING SURGEON: Dr. J. A. Smith ASSISTANT: Dr. Donald Marshall ANESTHESIA: General. 8

ANESTHESIOLOGIST: Dr. William Morris PREOPERATIVE DIAGNOSIS: Tumor, anterior right throat, lower thyroid lobe. POSTOPERATIVE DIAGNOSIS: Tumor, anterior right throat, lower thyroid lobe. OPERATION PERFORMED: Right thyroid lobectomy. OPERATIVE TECHNIQUE: The patient was prepped and draped in a routine manner under general anesthesia with endotracheal intubation. A soft rolled towel was placed under the shoulder blades to provide adequate extension of the head and neck. A transverse incision was made in the skin lines of the anterior neck approximately 2-3 fingerbreadths above the sternal notch. The subcutaneous tissue was divided with sharp dissection. The incision was approximately 4-5 inches in length. The subcutaneous venous and arterial bleeders were clamped and tied with 3-0 plain catgut. The cervical fascia was divided with sharp dissection, and the platysmal muscle split perpendicular to its line of fibers with sharp dissection. The vertical strap muscles were then identified on the right side and divided using Crile clamp and electric cautery dissection. Where necessary, bleeders were clamped and tied with 3-0 plain catgut. A Weitlaner retractor was then positioned for adequate exposure. The inferior thyroid artery and vein were then identified using blunt and sharp dissection. They were cross clamped and divided and tied with 2-0 chromic ligature. The middle and superior thyroid arteries and veins were also identified in a similar manner, cross clamped, and divided and tied with 2-0 chromic ligature. The thyroid lobe was mobilized medially using blunt and sharp dissection with Metzenbaum scissors. The recurrent laryngeal nerve could be identified in the tracheoesophageal groove and was protected posteriorly. With the right thyroid lobe being mobilized medially, the thyroid isthmus was soon identified and mobilized. The midthyroid isthmus was cross clamped using Crile clamps and divided. These clamps were then tied with 2- 0 chromic ligature. In this manner, the entire right thyroid lobe and proximal isthmus were removed in block. The dissection area was thoroughly irrigated with saline solution and sponged dry. When hemostasis was satisfactory and instrument, sponge, and pack count were correct, a small Penrose drain was placed in the depth of the incision and brought out through a separate stab wound in the area of the thyroid notch. The Penrose drain was sutured to the skin edge at that point with a single interrupted 3-0 silk suture. The subcutaneous tissue, including the fascia covering the platysmal muscle, was then approximated using interrupted 3-0 plain catgut. The skin incision was then closed with a subcuticular 3-0 plain catgut suture. An Adaptic 4 x 4 sterile towel dressing was then applied. The patient tolerated the procedure well and left the operating room in good condition. Transcription Exercise 3: Clinic Note (FamMed1BOS - Report #10) SUBJECTIVE: A 33-year-old white female, well-known to me, with questionable history of fibromyalgia versus atypical arthritic presentation. Patient has generalized joint pain which started this past year and affects her low back, hips, shoulders, hands, and feet. She has myalgias 9

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as well and fatigue, and patient, as noted in the past, has had both parvovirus as well as a positive Lyme titer, and the patient did have the Lyme vaccine. Patient has been tried on multiple anti- inflammatories, which have not given her a lot of relief. She also gets a GI upset from the anti- inflammatories. She has had a battery of tests done to rule out a rheumatoid arthritis, and these have all come back negative. Thyroid testing was also negative. Patient has also been seen by Rheumatology, and to date patient has not had a lot of relief of her symptoms. As noted previously and documented, the patient also has stiffness of the joints as well as some erythema and occasional swelling. OBJECTIVE: Patient has been seen several times in the past and an exam was not repeated today. ASSESSMENT/PLAN: After much discussion of her symptoms, the patient will be treated with a short course of steroids to see if this helps her symptoms and to assess whether or not there is a true inflammatory component to her current problem. She was placed on a steroid taper of prednisone and will follow up with me in 2 weeks. Patient was also placed on Prevacid 15 mg daily on an as-needed basis for when she does use anti-inflammatory . She uses Aleve at home and does get some relief from this. Patient agrees with this plan and will follow up with me accordingly. Transcription Exercise 4: Clinic Note (FamMed1BOS - Report #22) SUBJECTIVE: This patient is here for followup from the emergency room. She had swelling of her large toe, with purple discoloration and progressive pain which started 3 days ago. She went to the emergency room and was thought to have gout. An x-ray was done and was normal. ESR was 60, and a uric acid was 7.6. The patient was placed on Vioxx, as well as some Percocet according to patient. She has not taken the Percocet. She has taken the Vioxx 12.5 mg b.i.d. She has had some decreased tenderness and decrease in the discoloration. The toe is still quite painful. The patient is otherwise without any complaints. She states that she is tolerating the Vioxx, with only minimal GI distress. Patient has difficulty taking anti-inflammatories. OBJECTIVE: EXTREMITIES: Right large toe has tenderness, with mild edema and some mild purplish discoloration. There is no crepitus. Neurovascular is otherwise intact. ASSESSMENT AND PLAN: Resolving gouty arthritic attack. Continue with Vioxx 12.5 mg b.i.d. until pain-free. Patient may increase to 25 mg b.i.d. if her stomach tolerates this. She is to not use the foot as much as possible and limit all weightbearing. She may use warm moist soaks. Will recheck ESR today and reevaluate in 1 week and p.r.n. Patient agrees with plan. The patient will return to work in 1 week. Transcription Exercise 5: Thyroid Sonogram (Rad2BOS - #3363) THYROID SONOGRAM The right thyroid lobe measures 3.4 cm long by 1.1 cm AP. The left lobe measures 3.5 cm long by 1.2 cm AP. There are 4 small, round, 5-mm echo lucencies within the left thyroid lobe. This represents an increase of 1 as compared to the previous report from one year ago. The size of the 10

densities is about the same as previously described. There is one small hypoechoic density within the lower pole of the right thyroid lobe, also measuring 5 mm. OPINION: Bilateral small thyroid lesions, as described. Differential diagnosis includes multinodular goiter. Although one more is demonstrated on the left than was previously described, the size of the others and their appearance is unchanged. Task 12-7: Speech Recognition Exercises SRT Exercise 1: Clinic Note (AEAdvanced Unit 5 - Dictation 1) HISTORY OF PRESENT ILLNESS: The patient is a 26-year-old known HIV positive male with a chief complaint of increased cough. He was seen prior to the day of admission and given some Rocephin. Because of no improvement with the Rocephin, it was decided that he should be inpatient for continued therapy. His diagnosis upon admission was right upper lobe pneumonia, ruling out Pneumocystis carinii pneumonia versus community-acquired versus tuberculosis. The patient is also HIV positive. HOSPITAL COURSE: He was begun on the Rocephin at 1 gram IV q.12 hours, Bactrim DS 4 p.o. b.i.d. which was subsequently changed to Bactrim DS 2 p.o. q.i.d., erythromycin 500 mg q.i.d. and nystatin swish and swallow with nystatin troches. The patient responded well to the therapy, his vital signs remained stable and he improved. We also obtained sputum cultures, fungal stains and acid fast stains. The sputum cultures grew pneumocystis. The other cultures and stains revealed only mild candida. No acid fast bacillus was noted. The patient had a white count of 7400, 47 segs, 1 band and 46 lymphs. The hemoglobin was 13.5 and the hematocrit 43.6. Creatinine was 0.8, and a UA was negative. Chest x-ray revealed a right upper lobe patchy infiltrate. DISPOSITION: The patient was discharged in stable condition and had a discharge diagnosis of right upper lobe pneumonia, not likely due to pneumocystis. DISCHARGE MEDICATIONS: Erythromycin 500 mg t.i.d. and Bactrim DS 2 tablets p.o. b.i.d. SRT Exercise 2: Clinic Note (FamMed1BOS - Report #30) SUBJECTIVE: This patient is a 26-year-old here for followup. The patient was seen on multiple visits previous to this and thought to have viral-type symptoms. Overall, these have resolved. Patient still has persistent fatigue, and she says that her stomach knots up. This is worse in the late evening and early morning. She has a dry mouth. Other than that, she states that she is back to her usual self. She has had no rashes, no nausea, vomiting, diarrhea. Patient denies any change in her hair or skin. She denies fever, chills, myalgias, or arthralgias at this time. 11

OBJECTIVE: HEENT: Patient’s mouth appears dry, otherwise unremarkable. COR: Regular rate and rhythm. LUNGS: CTA. ABDOMEN: Midepigastric tenderness, otherwise normal exam. Parvovirus and Mono screen negative. Epstein-Barr positive for IgG antibody only. ASSESSMENT AND PLAN: Probable resolution of viral illness, with second disease state. Rule out gastritis, thyroid, and Lyme. Will check blood work for these. If all laboratory within normal limits, will consider an ultrasound of the gallbladder. Patient agrees with plan. Patient placed on Prevacid 30 mg daily for 1 week, then 15 mg daily. Discussed gastroesophageal reflux disease and dietary restrictions. 12

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