General Medicine Case Studies

7/29/2019 General Medicine Case Studies

1/35


2/35

A young woman of 24 went to her GP saying

that for the last two or three weeks she had

felt feverish and unwell with a sore throat.Apart from a tonsillitis the only other finding

noted was a slightly tender enlarged gland in

the neck. She was started on ampicillin but

stopped this two days later because of a skin

rash. She continued to feel generally unwell

over the next two weeks and returned to see

her doctor found Hb 10.1g/dl. WBC7,000/mm3 (2% atypical monocytes.

Platelets 155,000/mm3. ESR 35.


3/35

She was treated with iron and multivitamins

but continued to deteriorate and become

weaker. Three weeks later when she wasadmitted to hospital her blood was Hb

4.5g/dl. WBC 2,000/mm3. platelets

90,000/mm3.

There was no lymphadenopathy and no

abnormal physical signs.

1. What are the two most likely diagnosis?

2. What are the 3 most usefulinvestigations?


4/35

A 71 year old farmer went to his GPcomplaining of low backache, lethargy and

recent weight loss. It had come on graduallyand had worsened over the last two months.He described it as a constant nagging painthat was not related to posture so that he

found it impossible to lie or sit comfortably.There was no radiation of the pain to his legsor groin. There was a vague tenderness inthe region of the 3rd and 4th lumbar vertebrae

made worse by jarring. On examinationmovement of the spine were full and notpainful.


5/35

Straight leg raising was normal. There were

no abnormal physical findings elsewhere. X-

rays of the lumbar spine and pelvis showedno boy abnormality but he had a Hb 10g/dl.

And ESR 120.

1. What are the 3 most likely diagnoses ?2. What would be the 6 most useful

investigations?


6/35

A man of 54 presented with earache, tinnitus

and deafness in his left ear for several days.

That day he said he found it difficult no todribble and had noticed watery blisters on his

left ear

On Examination he was found to have a leftlower motor neurone lesion of the seventh

nerve and left nerve deafness together with

cutaneous vesicles in the eternal auditory

meatus and a few ulcerating lesions on theleft soft palate.


7/35

Physical examination was otherwise entirely

normal.

Investigations showed: Hb 12.2g%, WBC7,300/mm3. ESR 86, CXR is normal. Urea

43 mg%, Na 137 mEq/l , K 4.2 mEq/l, Ca

9.9mg% , phosphorus 3.2 mg%, bilirubin0.9mg% , alkaline phosphatase 12KA units ,

albumin 3.2 g%, globulin 6.4 g%,

electrophoresis an abnormal peak in the

globulin range.


8/35

1. What was the cause of his earache?

2. What was the cutaneous nerve supply of

the area involved ?3. Suggest the 4 most useful investigations

indicated in view of his high globulin.


9/35

A 50 years old Indian epileptic woman. Who

had been well controlled on phenytoin for

many years, came to medical outpatientswith a 3 month history of tiredness and a 3

weeks history of mild watery diarrhea. In her

past medical history she had had TB treated

with triple chemotherapy ten years

previously.

OE: the only abnormal finding were that she

was clinically anaemic and thin.


10/35

Investigation showed : Hb 8g/dl, MCV 112 fl ,

ESR 60 , B12 60ng/l. folate 60 g/l. faecal fats

28 mmol/24h

1. What is your diagnosis

2. Suggest the 6 most useful investigationthat should be carried out.


11/35

a 48 year old woman had been working in aneast African mission hospital for 3 years whereshe had looked after the physiotherapy and

radiology departments where she had worked 2afternoons a week. Following an attack of adiarrhea she went to her doctor and was foundto have a Hb 8.2g% , WBC 2300/mm3 (70%lymphocytes ), platelets 60,000/mm3 . Therewas no history of drug ingestion in any form.She was not on a contraceptive pill and did nottake any malaria prophylaxis . Apart from beingpale there were no abnormal physical signs and

a bone marrow biopsy showed a uniformdecrease in all elements with fatty replacement ,no abnormal cells were seen


12/35

It was felt she should stop working in the radiologydepartment . She continued to be pale and 6 monthlater she returned to England where she was given

unknown quantity of iron , folic acid and vitaminB12. on year after her return to England she wasseen in Out patients where she was found to haveHb 6.2 g/dl , WBC 1800/mm3 (lymphocyte 65%) ,

platelets 60,000/mm3 . A splenic tip was palpablecareful examination but there was no hepatomegalyand no other abnormal signs. Two attempts atsternal marrow biopsy was unsuccessful.

1. What are the 3 most likely diagnoses?

2. What would be the 4 most usefulinvestigations?

3. How would you monitor the progress ?


13/35

A 37year old woman with CRF had received

a cadaveric renal transplant 5 years

previously. Early rejection episodes had beentreated successful with steroid and

azathioprine and for the past 2 years she

had remained well on a maintenance dose of

these 2 drugs. 3 weeks before admission

she had begun to feel ill with anorexia, loss

of weight and sweating. For the past 2 days

her urine become dark and her husband saidthat her skin had become yellow and that

she was confused


14/35

On Examination she was ill , confused and

icteric/ she had fever of 39 and a tremor was

noted. The pulse was 105 bpm , BP ws110/70 mmHg, JVP and heart were normal /

the lungs were clear. In the abdomen the

liver was palpable , tender and 4 cm

enlarged.

Investigation showed Hb 9.9g%, WBC

12,000/mm3 , urea 40mg% , Na 137 mEq/l,

K 4.3 mEq/l, Bil 14mg% , SGOT 430 IU/L ,alkaline phosphatase 29 KA units, S. Alb

2.9g% , globulin 4.7g%


15/35

Urine : urobilinogen +ve , bilirubin +ve

1. give 6 possible causes for her jaundice

2. What 6 immediate investigations areindicated?


16/35

A 4 year old boy was brought by his parents

to the family doctor. They thought he might

be backward in speech and behavior andwere worried. On further questioning the

doctor was told that the boy was passing

large quantities of urine and was always

thirsty. In his past medical history he had had

a fit at eighteen months but had not been

investigated for this. A brother had died aged

4 months


17/35

O/E: the child was sick and dehydrated and

did indeed appear mentally backward. There

were no abnormal finding elsewhere. He wasadmitted to hospital for investigation and

observation. Urine analysis showed no

protein or glucose and his IVP was normal.

1. Give the most likely diagnosis

2. What 5 investigations are appropriate inthis case?

3. What 2 steps would you include in hismanagement?


18/35

A woman of 25 went to see her GP as she

had developed intermittent fever , muscle

pains , listlessness and had felt unwell for 3weeks

O/E she was pyrexial (38) and had several

slightly tender enlarged lymph glands in herneck. The only other abnormal findings were

that she had a palpable liver and the spleen

tip was also felt. In her left groin she had

some enlarged lymph glands. The rest of theexamination was normal.


19/35

Investigation: Hb 13 g%, ESR 40 , WBC

6,000/mm3 (50% lymphocutes) , platelets

250,000/mm3 . Film showed some abnormalmature monocytes. LFT: SGOT 80 I.U,Bil

1mg% , alkaline phospatase 15 KA units ,

Paul Bunnel test is negative , CXR is normal

1. Give 5 differential diagnosis.

2. What are the 5 most usefulinvestigation?


20/35

A 77 year old spinster was admitted to

hospital with a 10 days history of vomiting ,

abdominal pain and dysuria. She had beentreated initially by her GP with co-trimoxazole

(septrin); when she showed no response to

this she was given a subsequent course of

tetracycline. She was a late onset diabetic

controlled by cholropropamide 250mg daily

and a diet. During the last 2 or 3 days before

admission she had 2% glycosuria but noketonuria.


21/35

in her past medical history she had had

intermittent UTI which normally responded to

treatment. The only other fact of note wasthat she had suffered for many years from

frequent headaches for which she took

proprietary analgesics.

O/E: she had a healing erythematous rash

on her arms . The rest of her examination

was normal a part from her blood pressure of

180/100 mmHg and grade II hypertensivechanges in the retinal vessels.


22/35

Investigation: Hb 11g%, urea 250mg% , Na

130mEql/l , K 5 mEql/l, urine culter showed

growth of Ecoli sensitive to nalidix acid.She was treated with nalidixic acid to which

she responded well and a week later she

was symptom free and her blood urea was110mg%

3 weeks later she develop a further attack of

pain and dysurea and suddenly developed

anuria


23/35

1. suggest 2 ways in which the drugtherapy has contributed to her renal

failure2. How might the AB have influenced her

control of DM

3. Suggest 2 other possible causes for heranuria


24/35

A 23 year old, builder presented with a fever ,

pleuritis and cervical lymphadenopathy . No

other abnormalities were found onexamination. A histological diagnosis of

Hodgkins disease was made from a lymph

node biopsy.

What 3 steps in the management of this patient

would you consider at this time ?


25/35

With specific therapy remission was obtained.

6 months later he returned with fever ,

malaise and a cough productive of whitesputum . His GP had prescribed ampicillin.

His condition worsened and on admission to

hospital CXR showed patchy consolidation in

the right upper and mid zones and in the left

mid zone. Sputum culture grew a few

Candida only blood culture was negative


26/35

Despite vigorous antibiotic therapy he

deteriorated and died 5 days later

1. Give 3 causes for his relapse2. What 4 investigations would you have

performed on his 2nd admission


27/35

A 19 year old typist presented with a 4 day

illness of fever. Sweating , pain ad weakness

in the left shoulder and left upper arm. Shehad previously been in a good health except

for a 3 day episode of lower abdominal pain

two weeks previously. Which was associated

with some vaginal discharge and for which

she was prescribed amipicillin by her GP . In

reference to a VD clinic no evidence of

venereal infection was found.


28/35

O/E she had a pyrexia of 39.5 and wasobviously ill. There was severe pain andlocalized tenderness over the left scapulaand left humerus where firmed swellingswere palpable. Movement of the arm wasseverely restricted by pain. The skin was hot

and reddened and fasciculation was noted.Investigation showed Hb 13g%, WBC

14,000/mm3 , ESR 70 , CXR of should jointand humerous showed no abnormality .

EMG: showed polyphasic potentials withincreased insertion activity


29/35

1. Give 4 further investigations

2. Give 2 possible diagnosis


30/35

An 82 year old male had been admitted for 4

times in the previous year for malaise ,

lethargy and extreme pallor. On eachoccasion he had be found to be anemic but

apart from invariable finding of +ve occult

blood, no definitive diagnosis had been

made. During this period he had received

several course of oral iron and on 2

occasions he was transfused for pints of

Packed RBCs. He smoked 10 cigarettes aday , drank 2 or 3 whiskies each evening and

ate reasonable foods.


31/35

On he latest admission examination revealed

pallor but no jaundice , lymphadenopathy , or

clubbing and no signs of chronic liverdisease. His pulse was 80 bpm regular

rhythm , BP 170/95 mmHg , JVP normal, the

heart sounds were unremarkable and the

respiratory system was normal. In the

abdomen the liver was enlarged 3 cm below

the right costal margin and the spleen 2 cm

below the left costal margin. Rectalexamination was normal


32/35

Investigation showed: Hb 7gm% , WBC6,000/mm3 , reticulocyte 4%, ESR 25 , Ureaand electrolyte Normal , S.Iron 4.9umol/l, TIBC

80umol/l, Serum B12 and folate were normal.Barrium swallowing meal, follow through andenema were normal, Sigmoidoscopy revealedno abnormality and occult blood was

persistently +ve.

1. Give 4 possible causes for this anemia

2. Give 2 likely causes for the splenomegaly

3. What 2 further investigation would youundertake


33/35

A 28 year old women journalist went to see

her GP as the she had been feeling unwell.

For 6 weeks with anorexia , lethargy, jointpain and a loss in weight of more than a

stone.

O/E she was thin , pale , pyrexial and

jaundiced. Her abnormal physical findings

were confined to her abdomen were she had

a palpable liver 3 cm below her right costal

margin. And the tip of the spleen was alsopalpable


34/35

Investigations: Hb 11g%, WBC 6000/mm3 ,Bil

2mg%, Alkaline phosphatase 20 KA units,

SGOT 800 IU, Albumin 2.4 g% , Globulin 4.3g%.

1. What 2 further points from her historyshould be documented?

2. Give 5 possible diagnosis

3. What 5 further investigation would helpyou establish a diagnosis?

A 78 year old lady was admitted for investigation, for the past two months she


35/35

y y g phad been generally unwell, lethargic and anorectic and complaining ofgeneralized muscular pains and Arthralgia in shoulders, hips and wrists. Hergeneral practitioner had tried her on an Iron/folate combination after vitamintablets had not improved her symptoms. On the week before admission shehad become slightly confused at night with a tendency to fall.

Past medical history included a Cholecystectomy 30 years ago and aMyocardial Infarction 6 years previously, from which she had made a goodrecovery. She had been on Bendrofluazide (10 mg) daily since her MyocardialInfarction.

On examination she was well orientated, with a temperature of 37.3 C. Herconjunctivae were pale with two small petechiae on the left. She was notcyanosed or dyspneic. Her BP was 160/95 mmHg, pulse: 100 beats/min and

regular with a fair volume. The left ventricle was enlarged. The heart soundswere normal with a soft pansystolic murmur at the apex. Her respiratory systemwas normal, and in the abdomen the spleen tip was just palpable. The centralnervous system was normal, with no proximal muscle weakness. Generalexamination showed osteoarthritis of the left knee and Heberden nodes on thefingers. Both temporal arteries were palpable and non-tender.

Investigations showed: Hb 9.8 g/dl, MCV 86 fl, MHCH 30 g/dl, WBC8.6x109/l, platelets 470x109/l, ESR 78 mm/h, Urea and electrolytes and liverfunction tests were normal. Chest X-Ray showed left apical calcification andmoderate cardiomegaly. Serum B12 and red cell folate were normal. Serumiron was 10 umol/l Total Iron Binding Capacity was 36 umol/l MSU showed fourred cells/high powered field, with no growth.

What is the diagnosis?

How would you confirm the diagnosis and give 6 other useful investigations

Date post:	04-Apr-2018
Category:	Documents
Upload:	mohab-garawany
View:	220 times
Download:	0 times

General Medicine Case Studies

Documents