Immune System


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M45_F1.jpg"}},{"insert":"\n\n"},{"insert":"You scribble something resembling a signature on the dotted line at the bottom of the page, and with a heaving sigh, drop your pen on the desk and lean back in your chair. \r\n\r\nYour paperwork is finally up to date, and you swear that if you have to sign your name one more time today you\u0027ll explode.\n\nYou start thinking about how much time off you\u0027d get if you did, before the thought is cut short by the sharp beep of your phone.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M45_F2.jpg"}},{"insert":"\n\n"},{"insert":"Your first patient of the day - you pick up the sheaf of completed paperwork and stick it in a desk drawer, and try to make your desk look presentable.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M45_F3.jpg"}},{"insert":"\n\n"},{"insert":"In walks a cheerful-looking young woman. You glance at her file and find that she\u0027s 32 and a brand new patient, here for her first appointment with you.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M45_F2.jpg"}},{"insert":"\n\n"},{"insert":"She introduces herself as Tara, and you shake her hand and say hello before motioning for her to take a seat. You ask her how you can help.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M45_F5.jpg"}},{"insert":"\n\n"},{"insert":"\u0022Well I\u0027ve had a bit of pain in my groin recently - which I\u0027ve been trying to manage myself - but my fianc\u00e9 has been hassling me to come see someone about it, so here I am.\u0022\n"}]}


{"ops":[{"insert":"You ask her about the nature of the pain, and whether or not she remembers when it started.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M45_F7.jpg"}},{"insert":"\n\n"},{"insert":"\u0022Well, I have a horrible pain when I use the toilet, and my bladder always feels full. It\u0027s quite uncomfortable. I\u0027ve also had a little bit of blood in my urine from time to time.\r\n \r\nIt\u0027s been this way for a couple of weeks. It started with just a little discomfort, but then it got more painful as time went on.\u0022\n"}]}


{"ops":[{"insert":"You decide to ask a few questions about Tara\u0027s social and family history to get a fuller picture of her general health.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M45_F9.jpg"}},{"insert":"\n\n"},{"insert":"Tara is happy to discuss her social history, and reveals that she has never smoked, and hasn\u0027t consumed alcohol since the age of 21-23, before when she had only a moderate consumption. There\u0027s no history of recreational drug use either. \r\n \r\nShe takes regular exercise and maintains a healthy, balanced diet.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M45_F10.jpg"}},{"insert":"\n\n"},{"insert":"You ask her about her family\u0027s health, and she mentions a family history of hypertension - both her father and paternal uncle take propranolol for high blood pressure. She adds that she isn\u0027t on any long-term medication and hasn\u0027t been since she was a child.\n"}]}


{"ops":[{"insert":"Concerned by her family history and implied an aversion to seeking medical attention, you ask if she has had her own blood pressure monitored or has ever been concerned with her family history.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M45_F12.jpg"}},{"insert":"\n\n"},{"insert":"\u0022Oh no, I just make sure I have a healthy diet and use natural remedies to prevent any problems. I try to stay away from doctors and hospitals if I can.\u0022\n"}]}


{"ops":[{"insert":"You ask if you can make a few simple measurements and observations - she agrees, and you ask her to roll up her sleeve so you can start by measuring her blood pressure.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M45_F14.jpg"}},{"insert":"\n\n"},{"insert":"You record her blood pressure as 110\/70mmHg and her resting pulse at 72bpm.\r\n \r\nYou ask Tara to stand up, and measure her height as 5\u00275\u0022 (165cm) and her weight at 123lbs (55.8kg), giving her a BMI of 22kg\/m2. Upon inspection, you find no abnormalities or pathological signs.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M45_F15.jpg"}},{"insert":"\n\n"},{"insert":"Based on what she has told you and what you have observed, you begin to consider what might be causing Tara\u0027s symptoms.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M45_F5.jpg"}},{"insert":"\n\n"},{"insert":"In order to rule out some possibilities, you ask a few more questions. You ask if she\u0027s experienced any redness or irritation around the genitals or any unusual discharge. She replies that she hasn\u0027t had any of that.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M45_F17.jpg"}},{"insert":"\n\n"},{"insert":"You ask if Tara would mind you performing a quick examination, and she agrees.\r\n \r\nShe lays on the couch, and you examine her abdomen and pelvis. She reports no tenderness and you see no swelling or visible signs of pathology.\n"}]}


{"ops":[{"insert":"Having gathered a bit more information about Tara\u0027s condition, you begin to suspect that Tara may be suffering from a urinary tract infection. You consider your next step.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M45_F3.jpg"}},{"insert":"\n\n"},{"insert":"You decide to do a quick dipstick urinalysis to further investigate the cause of Tara\u0027s symptoms. You ask her when she last emptied her bladder.\r\n \r\nAfter some thought, she replies that she last used the bathroom just after she woke up, which she estimates as about 6 hours ago.\n\nYou hand her a pot and ask her to provide a urine sample for analysis. She agrees and makes her way out to the restroom.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M45_F20.jpg"}},{"insert":"\n\n"},{"insert":"Tara returns a few minutes later with a sample in hand. You perform a urine dip test, and it shows no abnormalities or signs of infection. You do find a small amount of blood, but it\u0027s within the normal range and not clinically significant.\n"}]}


{"ops":[{"insert":"With all the information you\u0027ve gathered and no sign of infection on the dipstick, you consider your next step.\n"}]}