Case Study

600

Faculty of Medicine MUST

Normal Values
Serum Serum Serum Serum Serum Serum Serum ESR Serum Serum Serum Serum Na (135 - 145 meq/L) K (3.3 4.7 meq/L) Billirubin (less than 1 mg/dl) Albumin (3.5 5 mg/dl) Globulin (2 2.5 gm/dl) SGOT / AST (10 45 Iu/L) Alkaline Phosphatase (40- 125 Iu/L) (males 0-10 / females 3-15) B12 (130 770 pg/ml) Calcium (8.5 11 mg/dl) Urea (15-40 mg/dl) Creatinine (.7 1.4 mg/dl)

Hepatitis Markers
HAV: HAVab (IgM) HBV: HBVsAg, HBVeAg, HBVsAb, ABVeAb, ABVcAb HCV: ELISA, PCR HDV: HB Markers + HDVAg, HDVAb, HDV RNA Chronic Hepatitis: HB + HC + HD Markers

General Medicine 600 Case Study

Case 1:
24 years old male student has 3 week history of low back pain, especially in the morning, 3 days before he got abdominal pain and diarrhea then fever, on examination: -Feverish -Tender Palpable Mass in The Rt. Illiac Fossa -PR Examination is Normal -Sigmoidoscopy is Normal -Tenderness on The Lubmosacral Spine Investigations: -Hemoglobin = 9 gm/dl -ESR = 60 -WBCs = 10.000 -Stool Analysis (-ve)

Anemia High High Normal Value

a- What is Your Diagnosis?

Crohns Disease: -With: Fever, Anemia, Pallor, Tender Rt. Illiac Fossa -Against: No Bloody Stools -Extraintestinal Manifestation of Crohns: Spondylitis, Arthritis, Iritis, Gall Stones, Skin Lesions(Erythema Nodosum)

b- What is the Differential Diagnosis?

1-Appendicular Mass: -With: High ESR, Fever, Tenderness, Sigmoidoscopy -Against: Normal WBCs, Stool Analysis, Anemia, No Acute Onset, Low Back Pain 2-Tuberculosis of Illeocecal Junction: -With: Fever, Mass, High ESR, Low Back Pain (Potts Disease) -Against: (-ve) Stool Analysis, No Symptoms of Toxemia, Short History, No 1ry Pulmonary Focus

3-Cancer of Illeocecal Junction -With: Fever, Anemia, Low Back Pain -Against: Age, No Cachexia, Rapid Onset, No Carcinoid Manifstations 4-Ulcerative Colitis: -With: High ESR, Diarrhea, Anemia -Against: Sigmoidoscopy not Showing Lesions, Normal Stool Analysis (no Occult Blood)

c-

What are Further Investigations Needed?

1-Imaging & Endoscopy: X-ray Chest: TB Focus X-ray Abdome: Skip Lesions of Crohns X-ray Lumbosacral Spine CT/MRI: Potts Disease Abdominal Ultrasound Colonoscopy 2-Laboratory: Tuberculin Test or PCR Sputum Analysis HIAA: Carcinoid Marker 3-Biopsy: Laparoscopy or Laparotomy ________________________________________________________________

Case 2:
27 Years old Male complains of severe cramping central chest pain for 8 hours, worse on exhersion (Typical Chest Pain) he is smoker, but no history of any previous illness on examination: -BP = 120/70 mmhg Sound Timing Characteristics Mechanisms Variable features -Pulse = 90/min Regular -Cardiac Size is normal Absent in atrial Ventricular origin (stiff fibrillation -No signs of Heart Failure End of ventricle and A feature of severe left diastole, Low pitch augmented atrial ventricular -4th Heart Sound is Audible just before contraction) related to hypertrophy (e.g. S1 atrial filling hypertrophic -X-ray is Normal cardiomyopathy) -ECG Showing Recent Anterior Infaction

S4

Note: Pt. Was Diagnosed as Myocardial Infaction

a- What are the most important 4 investigations needed on his recover?

1- Lipid Profile 2- Blood Glucose 3- Clotting Time 4- Angiography Catheter Echocardiography

b- What are 2 other physical signs may patient has?

1- Xanthoma- Xanthelasma- Arcus Senilis 2- Dehydration Acetone Odor 3- Signs of Rheumatoid Arthritis Hyperlipidemia Diabetes Mellitus Autoimmune

c-

Give 4 Useful Advices for This Patient

1- Decrease or Stop Smoking 2- Exercise 3- Lipid Restriction 4- Substitution of Saturated Fatty Acids With Polyunsatured fat 5- Omega-3 & Fish Oil 6- Avoid Sedentary Life

d-

Why the Patient Has 4th Heart Sound?

Akinesia of the Right Ventricle Leading to Diastolic Dysfunction & 4th Heart Sound ________________________________________________________________

Case 3:
71 years old farmer went to his GP complaining of low back pain, lethargy and recent weight loss, it had come on gradually and had worsened over the last two months, he described it as a constant nagging pain that was not related to a posture so that he found it impossible to lie or sit comfortably, there was no radiation of the pain to his legs or groin (no spinal cord lesion), there was a vague tenderness in the region of the 3rd and 4th lumbar vertebrae made worse by jarring. On examination movement of the spine were full and not painful Straight Leg Sign was normal, there were no abnormal physical findings elsewere. X-ray of the lumbar spine and pelvis showed no bony abnormalities but he had hemoglobin 10 gm/dl (Anemia) ESR 120 (n=10 males 15 females) (Very High Suggestive Malignancy)

a- What are the 3 most likely diagnoses?

1-Multiple Myeloma Plasma Cell Tumor of BM: (most common) -With: Old Age, Tenderness, Loss of Weight, Anemia, Gradual Onset, Very High ESR, Lethargy -Against: No Other Manifestations of Multiple Myeloma 2-Osteosarcoma: -With: Old Age, Tenderness, Loss of Weight, Anemia, Gradual Onset -Against: X-ray Normal, Normal Movements of the Spine 3- 2ry Metastasis of Prostatic Cancer: -With: Old Age, Tenderness, Loss of Weight, Anemia, Gradual Onset -Against: No Urinary Symptoms of Prostate (Nocturia, Double Streaming of Urine, Retention of Urine) 4- Potts Disease: No Toxic Symptoms or Chest Manifestations 5- Lumbar Spondylosis: No Vague Pain 6- Lumbar Disk Prolapse: High ESR Normal Joint Function 7- Osteoporosis: From History Its Localized not Generalized

b- What are 6 most useful investigations for this patient?

1- CT/MRI Vertebrae 2- Prostatic Specific Antigen (PSA) 3- X-ray Chest 4- Bone Marrow Biopsy 5- Plasma Electrophoresis 6- Peripheral CBC (Differential) ___________________________________________________________________

Case 4:
A man of 54 presented with earache, tinnitus and deafness in his left ear for several days, that day he said h found it difficult not to dribble and had noticed watery blisters in his left ear, On examination he was found to have a left lower motor neuron lesion of the seventh nerve and left Eighth nerve deafness together with cutanous vesicles in the external auditory meatus and a few ulcerating lesions on the left soft palate, physical examination was otherwise entirely normal Investigations: Hb 12.2 gm/dl (Anemia), WBCs 7300, ESR 86 (High), CXR is Normal, Urea 43 mg% (n=20-40) (High), Na 137 mEq/L, K 4.2 mEq/L, Ca 9.9 mg/dl, Phosphorus 3.2 mg/dl, Billirubin .9mg/dl, Alkaline Phosphatase 12 King Armstrong Unit, Albumin 3.2 gm/dl (High), Globulin 6.49% (High), Electrophoresis an Abnormal Peak in the globulin range

a- What was the cause of his earache?

Ramsey-Hunt Syndrome (Facial Palsy + 8th Nerve Manifestations)

b- What was the cutanous nerve supply?

Trigeminal (Anterior) Vagus (Posterior)

c-

Suggest the 4 most useful investigations indicated in view of his high globulin?

1-Immunoglobulins Electrophoresis -Monoclonal gammopathy -Polyclonal gammopathy 2-Viral Scan: Herpes Zoster 3-Cryoglobulins 4-CSF Examination ___________________________________________________________________

Case 5:
50 years old Indian woman epileptic, who had been well controlled on phenytoin for many years, came to medical outpatients with 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 chemotheraphy for 10 years previously, On examination only abnormal finding were that she was clinically anemic and thin, Investigations: Hb 8g/dl (Anemia) MCV 112 ESR 60 (High) B12 60 mg/dl (Low) Folate 60 g/l Fecal Fat 28 mmol/24 h (High)

a-

What is Your Diagnosis?

aTropical Sprew (Malabsorption Syndrome): Parasitic Infestation causing putrefaction and malabsorption vit. B12 deficiency Macrocytic anemia ttt Tetracycline Reactivation of TB Enteritis: - Against: Normal CXR, no Toxic Manifestations, Fatty stools, watery Diarrhea Phenytoin Induced Anemia: - Against: Fatty stools

b-

c-

b- Suggest 6 Useful Investigations?

1- Stools Culture 4- Tuberculin Test 2- Barium Meal 5- Intrinsic Factor 3- CXR 6- Blood Chemistry

Case 6:
A 48 years old woman had been working in an east African mission hospital for 3 years where she had looked after the physiotherapy and radiology department where she had worked 2 afternoon a week, following an attack of diarrhea she went to her doctor and was found to have a Hb 8.2 g%, WBCs 2300/mm3 (70% Lymphocytes), Platelets (60.000/mm3), There was no history of drug ingestion in any form. She wan not on a contraceptive pill and didnt take any malaria prophylaxis, Apart from being pale there were no abnormal physical signs and a bone marrow aspiration showed uniform decrease in all elements It was felt she should stop working in the radiology department. She continued to be pale and 6 month later she returned to England where she was given unknown mount of iron, folic acid and vitamin B12. One year after her return to England she was seen in outpatients where she was informed to have Hb 6.2 g/dl, WBCs 1800/mm3 (Lymphocytes 65%), Platelets 60.000/mm3, a spleenic tip was palpable, careful examination but there was no hepatomegaly and no other abnormal signs. 2 attempts at sternal bone marrow aspiration was unsuccessful

a- What are the 3 most Likely Diagnoses?

1- Hypoplastic Anemia: -With: occupation, Pancytopenea, -ve BM Aspiration -Against: Lymphocytosis 2- Malaria: -With: African, no Vaccination, Lymphocytosis , Palpable Spleen Tip -Against: No Fever, No Other Manifestations of Malaria 3- Myelofibrosis: (Commonest) -With: Pancytopnea, 2 Unsuccesful Trials of BMA, Progressive Course, Occupation, Just Palpable Spleen -Against: Lymphocytosis 70%, Diarrhea 4- HIV: -With: lymphocytosis, pancytopenea, leucopenia, diarrhea -Against: just palpable spleen, no loss of weight, no repeated Blood -Early increase in T-Cells Then Decrease in T-Cells transfusion
-Early increase b-cell Ig then Increase in B-Cell Ig

b- Suggest 4 most Useful Investigations?

1- AIDS: CD4 PCR - ELISA 2- Myelofibrosis: Bone Marrow Biopsy 3- ESR, Blood Film 4- Anti Nuclear Antibodies 5- Malaria: Abdominal Ultrasound 6- Anti-DNA Antibodies 7- Stool Analysis for Diarrhea

c- How to Monitor Progress?

1-CBC 2-ESR

Case 7:
A 37 years old woman with CRF had received a cadaveric renal transplantation 5 years previously. Early rejection episode had been treated successfully with steroids and azethioprine and for the past 2 years she had remained well on a maintenance dose of these 2 drugs, 3 weeks before admission she had began to feel ill with anorexia, loss of weight and appetite and sweating, for the past 2 days her urine became dark On examination she was ill, confused and icteric (jaundice), she had fever of 39 and tremor was noted. The pulse was 105 BMP, BP was 110/70 mmhg, JVP and heart were normal, Lungs were clear, in the abdomen the liver was palpable, tender and 4Cm enlarged Investigations showed Hb 9.9 g% (Anemia), WBCs 12.000 (Leucocytosis), Urea 40mg%, Na 137 meq/L, Billirubin 14 mg% (Jaundice), SGOT 430 Iu/L (High), Alkaline Phosphatase 29 KAU (High), S.Albumin 2.9 g% (Low), Globulin 4.7 g% (High), Urine: Urobillinogen +ve, Billirubin +ve

a- What are the 3 most Likely Diagnoses?

1- Cholangiocarcinoma: commonest -With: Jaundice, Dark Urine, Alkaline Phosphatase, Anemia, Anorexia -Against: Age, Renal Failure & Transplantation 2- Hepatocellular Carcinome: -With: Anorexia, Loss of Weight & Appetite, Sweating, Tremors, Fever, High SGOT & Alkaline Phosphatase, Low Serum Albumin, High Globulin with Inverted A/G Ratio, Jaundice -Against: Age, Onset, CRF 3- Delayed Rejection of Kidney: -With: Hemolytic Anemia (A.Immune), Jaundice, Fever -Against: Dark Urine 4- Viral Hepatitis: -With: Immune-suppression, High Liver Enzymes, Jaundice, Fever -Against: Age, Onset, CRF 5- Drug Induced Hepatitis: -With: History of Corticosteroids, High Liver Enzymes -Against: Fever 6- Infectious Mononucleosis: -With: Immune-Supprssion, Fever -Against: No Lymphadenopathy or loss of weight

b- Mention 6 Immediate Investigations?

1-Abdominal Sonar 2- Hepatitis Markers 4-Viral Scan 5-Coagulation Profile 7-CT Scan With Contrast 3- Coombs Test (Hemolysis) 6--fetoprotein

Case 8:
64 Years old Was Admitted to the hospital for investigations of Anemia, He had been a heavy drinker for most of his life & smokes 20 cigarettes/day, for 2 month he had developed increasing shortness of breath on exertion & had felt unwell On Examination: He Was Clinically Anemic & Bilateral duputrine contractures were seen, his pulse was 66 Bpm, regular rhythm, BP 190/100 mmHg, There was no cardiomegaly, Heart sounds were normal and he was not in cardiac failure. Lung fields were clear, in his abdomen the liver was enlarged from below the costal margin & was soft & not tender; the spleen was palpable 7cm below the left costal margin Investigations: Hb 9.1 g/dl, PCV 30%, MCHC 30g/dl, Reticulocytic count 9x109 (n=2x109), Blood film Anisocytosis poly-chromasia (Different Shapes), Occasional Nucleated Red Cells ESR 30, Urea & electrolytes are normal, platelets 190.000/mm3, Plasma proteins are normal, Serum Billirubin 0.7 mg%, SGOT 16 IU, Urine: Urobillinogen not increased, Billirubin negative (no hemolysis), Direct Coombs test is negative, Serum iron 170 mmol, TIBC 530 mmol, LE Cells negative x3

a-

What is the most likely type of anemia from which this patient is suffering?
Iron Deficiency Anemia (Microcytic Hypochromic Anemia) -With: Alcoholic, Serum Iron, TIBC, PCV, MCHC, Anemia -Against: Hypertension, Signs of Liver Failure

b-

Give 3 possible diagnosis which might account for the observed findings
1- Liver Failure: -With: Contracture, Alcoholic, Soft non-tender Hepatomegaly, Dyspnea due to anemia, Spleenomegaly -Against: Normal SGOT, No Jaundice, Increased TIBC 2- Chronic Gastritis: -With: Alcoholic, low Serum Iron, Microcytic Anemia -Against: TIBC 3- Nutritional Iron Deficiency: -With: Alcoholic, low Serum Iron, Microcytic Anemia -Against: Signs of Liver Failure 4- Fatty Liver: -With: Alcoholic, Age, Soft Hepatomegaly

c-

Give the 4 most appropriate investigations

1- Ultrasound 2-Spinal CT 3- Liver Biopsy 4- Bone Marrow Aspirate + Biopsy 5- Serum B12 + Folic Acid 6- Occult Blood in Stools 7- Urine Analysis for Hematuria

Case 9: (VIP)
A 54 years old man had been admitted to hospital five years previously with a myocardial infarction. At the time he was found to have a BP of 180/115 mmHg but no underlying cause was discovered. For the past 2 years he suffered from arthritis of his knee, ankle & wrist joints for which he had been given a variety of drugs. But he had never taken steroids. On his occasion he was admitted to hospital with a 3 day history of swelling of his ankles and legs in addition to breathlessness which was worse at night On Examination: he was pale & obese, BP 190/120, Pulse regular 100 bpm, JVP raised 4cm, Ankle Oedema, There was Cardiomegaly and a Pansystolic murmer audible at the apex, his fundi showed a grade II hypertensive retinopathy and there were Crepitations at the lung bases

a- What are the 4 most Likely Causes in This Patient?

1- Rheumatoid (Vasculitis): commonest -With: -Against: 2- Ischemic Heart Failure: -With: -Against: 3- Hypertensive Heart Failure: -With: -Against: 4- Rheumatic Fever + Mitral Incompetence: -With: -Against: 5- Drug Induced Salt / Water Retention (NSAIDs): -With: -Against:
His Diuretics were increased and he was digitalized, but after 48 hours he developed severe chest pain (retrosternal) and palpitations. He had a regular tachycardia of 120 Bpm and his chest x-ray showed cardiomegaly with pulmonary edema

b- What are the 3 Possible Causes for Deterioration?

1- Another Infarction 2- Aortic Dissection 3- Pulmonary Embolism 4- Digitalis + MI = Arrhythmias & Thrombosis so Dobutamine is Given Instead

Case 10: (VIP)

23 years old builder presented with fever, pleurisy and cervical lymphadenopathy, diagnosis of Hodgkin lymphoma through lymph node biopsy

a- What are the 3 steps in management of this patient at this time?

This 123is a case of Stage IEB Hodgkin Disease Managed as follows: Local Chemotherapy (MOPP) Surgical Excision of Ipsilateral Cervical LNs Antipyretic for Fever & Antibiotics for Pleurisy

With specific therapy remission was obtained, 6 month later he recurred with fever, malaise, cough, sputum, his GP prescribed Ampicillin, his case was worsened, hospital admission & X-ray Chest revealed patch consolidation in the right upper-midzones & Left midzones, sputum culture revealed few Candida, blood culture was negative Despite vigorous antibiotic therapy he deteriorated and died after 5 days

b- Give 3 causes for his relapse

1- Inadequate Chemotherapy Dose 2- Severe Depression of Immunity 3- Missed Enlarged Mediastinal Lymph nodes During Diagnosis

c-

What are 4 investigations you would have made on 2nd admission

1- Leucocytic Count 2- Chest CT Scan 3- ESR 4- Tuberculin Test 5- BM Aspiration 6- Restaging Through Evaluation of Whole Lymph nodes in Body: - Abdominal CT & ECHO - Spleenic Aspirate & Biopsy - Liver Functions & Biopsy - Lymphography

Case 11: (VIP)

82 Years old male admitted for 4 times in the previous year for malaise, lethargy, extreme pallor, on each occasion had been found to be anemic but apart from +ve occult blood in stools no definite diagnosis has been made. During this period he has received several courses of iron and on 2 occasions he was transfused for packed RBCs, he smoked 10 cigarettes per day, drink 23 scotch per day, reasonable food On his latest admission examination revealed pallor but no jaundice, no lymphadenopathy, no clubbing, his pulse 80/min regular, no signs of chronic liver failure, JVP normal, heart sounds are normal, abdomen: more than 3Cm liver, more than 2Cm spleenomegaly, rectal examination is normal, chest is normal, BP 170/95 mmHg Investigations: hemoglobin 7gm/dl, WBCs 7000/mm3, Reticulocyte 4%, ESR 25, Urea + Electrolyte normal, S.Iron 4.9 mmol, TIBC 8 mmol, Serum B12 & Folate were normal, Barium swallow normal, follow through and enema were normal, sigmoidoscopy revealed no abnormality and occult blood was persistently +ve

a- Give 4 possible causes for this anemia

1- Parasitic Infestation (Commonest): -With: Hepatospleenomegaly, Low TIBC, Anemia, Low S.Iron, Occult Blood, High ESR -Against: Hypertension, No Esenophilia 2- Malabsorption Syndrome: -With: Alcoholic, Occult Blood, Pallor, Age -Against: no Diarrhea 2- Chronic Gastritis /Gastric Erosion: -With: Alcoholic, low Serum Iron, Anemia -Against: TIBC, High ESR, No Epigastric Pain, Hepatospleenomegaly 3- Nutritional Iron Deficiency: -With: Alcoholic, low Serum Iron, Anemia -Against: High ESR, Occult Blood 4- Fatty Liver: -With: Alcoholic, Age, Hepatospleenomegaly -Against: Low Serum Iron, Low TIBC, Occult Blood

Case 12:
28 years old woman journalist went to see her GP as she had been feeling unwell for 6 weeks with anorexia, lethargy, joint pain and loss of weight of more than a store On Examination she was thin, pale, pyrexia and jaundiced, her abnormal physical findings were confined to her abdomen, where she had a palpable liver 3Cm below right costal margin. And the tip of the spleen was also palpable Investigations: Hb 11g%, WBCs 6000/mm3, Billirubin 2mg%, Alkaline Phosphatase 20 K unites, SGOT 800 iu, Albumin 2.4 g%, Globulin 4.3 g%

a- Give Further 2 points in history should be documented

Drugs Travel Blood Transfusion Family History

b- Possible 5 diagnoses
1- All Types of Hepatitis (a-b-c-d-e): commonest -With: jaundice fever IP 6 days Hepatomegaly - Enzymes -Against: hyperglobulinemia no extra hepatic manifestations of HCV 2- Cholangiocarcinoma: -With: -Against: no hypochondrial pain Billirubin is not so much elevated 3- Autoimmune (Vasculitis): -With: loss of appetite weight loss - anemia -Against: jaundice (except in cases of infarction or hemolysis) 4- IMN / Malaria 5- Malabsorption (no diarrhea) 6- Leukemia -Against: High Alkaline Phosphatase

c- Further 5 investigations
1- Sonar 2- CT 3- Biopsy 4- Hepatitis Markers 5-Bone Marrow Examination 6- Alpha-fetoprotein 7-Antinuclear antibody 8- Anti CCB

Case 13:

missed case

25 Years old Female Presented to the hospital with Fever, Muscle Pain, Swelling in the neck On Examination : Spleenomegaly, Hepatomegaly Investigations: Hb 13g%, Billirubin 1mg%, ESR 40

a- Possible 4 diagnoses
1- Hodgkin Lymphoma: commonest -With: fever Hepatomegaly Spleenomegaly High ESR Muscle Pain -Against: ESR is not much high suggesting tumor Absence other Manifestations of Lymphoma 2- Leukemia: -With: fever Hepatomegaly Spleenomegaly High ESR Muscle Pain -Against: ESR is not much high suggesting tumor Absence other Manifestations of Lymphoma 3- Hepatitis: -With: Hepatospleenomegaly Fever -Against: normal Billirubin - Lymphadenopathy 4- Malaria : -With: Fever Muscle pain Lymphadenopathy-Hepatospleenomegaly -Against: no Characteristic Pattern of Fever no Other Manifestations of malaria

b-

Further investigations
1- Leucocytic Count 2- Chest CT Scan 3- ESR 4- Tuberculin Test 5- BM Aspiration 6- Hepatitis Markers 7- Staging Through Evaluation of Whole Lymph nodes in Body: - Abdominal CT & ECHO - Spleenic Aspirate & Biopsy - Liver Functions & Biopsy - Lymphography

Case 14:

missed case

82 Years old Male Presented with pallor, anemia, occult blood, he is known to be smoker, drinker, no jaundice, no lymphadenopathy On Examination : Hepatospleenomegaly Investigations: Hb 7g%, WBCs 6000/mm3, ESR 25, B12 & Folic Acid are normal

a- Possible 4 causes of anemia

1- Diverticulosis: -With: Pallor Anemia Occult Blood Age - Male -Against: Hepatospleenomegaly 2- Crohns Disease: -With: Age Pallor Anemia Occult blood smoker drinker HSM -Against: ESR is not much high suggesting tumor no Abdominal Pain 3- Cancer Colon: -With: Age Pallor Anemia Occult blood smoker drinker HSM Hepatospleenomegaly -Against: no Lymphadenopathy ESR is not that much high 4- Ischemic Colitis: -With: Pallor Anemia Occult Blood -Against: Hepatospleenomegaly no Abdominal Pain

b-

Further investigations
1- Colonoscopy 2- Hepatitis Markers 3- Blood Culture 4- Tumor Markers

Case 15:
58 years old has marked clubbing and S.O.B. recently. He is heavy smoker and always have chronic cough (Chronic Cough + History of Smoking = Bronchitis) On Examination: Bilateral Basal Crepitations on chest, No cyanosis, no CVS abnormality, X-Ray Chest showing diffuse reticular pattern at lung base Investigations: PaCO2: 35mmhg (High), PaO2: 94 mmhg (Normal), FEV1: 1.7 L (N=2.53.5), FEV1/VC: 68% (N= over 75%), Total Lung Capacity: 4.7L (N=5.5-7.3), Co Diffusion: 7.9 mlCo/Min

a- Describe Pulmonary Abnormalities

Lung Abnormalities are Either (Obstructive = Lesion in Bronchi) (Restrictive = Lesion in Alveoli)

The Lesion Here is Restrictive:

- With: Low FEV (Forced Expiratory Volume), Low FEV/VC, High CO2 Partial Pressure Due to Minimization of Exchange Function, Low CO Diffusion

b- Possible 6 diagnoses
1-Hamabnn Rich Syndrome (Idiopathic Pulmonary Fibrosis) 2- Collagen Lung Disorder as Scleroderma or Rheumatoid A. 3- Sarcoidosis but no Hilar Lymphadenopathy or Skin Manifestations 4- Lymphangitis Carcinomatosis 5- Extrinsic Allergic Alveolitis 6- Other: Hemosidrosis or Hemochromatosis

c- What Would Happen to PCO2 and PO2 on Exhersion?

Tachypnea leading to more wash to CO2 and Increase of PO2

Case 16:
44 Years old Female Complains of Loss of Weight about 10 Kg over the last 6 month, during this time she had intermittent Epigastric pain, two weeks previously she had developed a generalized itching and noticed that urine was dark she had never been in hospital before, she drunk a small amount of alcohol and had not been in contact with anybody with jaundice, she had not taken any medications nor had been given any injections in past 6 months On Examination: Jaundice, Rubbery nodules on her elbows (Xanthoma), enlarged liver 10 Cm, No Acitis nor Spleenomegaly Investigations: CXR: Normal, Hb: 12 gm%, WBCs: 8000/mm3, Billirubin: 5 mg%, Alk.Po4: 40 KAU, AST: 30IU, S.Cholesterol: 360 mg%

a- 4 Possible Causes for Disease

1- Gall Stone 2- Pancreatitis 2- Cancer Head of Pancreas or Cholangiocarcinoma -Against: Pain 4- Billiary Cirrhosis -Against: Epigastric Pain, Loss of Weight

b- 4 Causes of Epigastric Pain

abcdChronic Pancreatitis (Colicky Intermittent) Cholecystitis Hepatitis (Dull Aching) Chronic Gastritis from Alcoholism

c- 6 Investigations
1- ERCP 2- Ultrasound 3- PTC 4- Lipase / Amylase 5- Lipid Profile 6- MRCP

Case 17: VIP

47 years old female admitted to the hospital 2 days history of chest pain radiating to both arms and associated with shortness of breath, sweating, palpitations, on carrying heavy weight, 26 years ago she had pleurisy and was hospitalized for 1 year (=TB), 10 years ago she was diagnosed to had myasthenia gravis (Thymoma), she was given only anticholinesterase On Examination: Myasthenic face, Temp. 37.5 C, Pulse 140/min, Regular, poor volume, BP 90/60 mmhg, JVP Raised to angle of jaw, Apex is not palpable and distant heart sound but no murmers Chest is normal Except for dullness on left base Liver Palpable, Bulbar weakness and generalized weakness of 4 limbs Investigations: Hb: 11.9 , WBCs: 14000, ESR 115 (Malignancy Suspected), BUN + Na+ K are normal, CXR: enlargedhart and left pleural effusion, ECG: low voltage, Sinus tachycardia with deressed ST segment in limb leads Case Analysis: 1- Myasthenic Crisis: but no High Fever 2- Myocardial Infearction: - Against: ST Dpression, Cardiomegaly, Distant HS, no Apex, Atypical Chest Pain 3- Malig. Pericardial Effusion on top of Pericarditis Causing Cardiac Tamponade (Commonest)

a- Give 2 Causes for her Recent Deterioration

1- Myasthenic Crisis but no Fever 2- Cardiac Tamponade From Malignant Pericardial Effusion as Thymoma Can Transform Into Malignant

b- How Past History Can Explain Her Cardiac Findings?

Malignant Pericardial Effusion -------------------< Cardiac Tamponade a- Shock 90/60 D- Distant HS b- No Apex E- low Voltage Depressed ST Segment c- Raised JVP

c- 6 Investigations
1- CT Scan Chest 2- Tumor Markers 3- Tuberculine Test 4- Acetyle Choline Ab Titre 5- ECG 6- Chest ECHO

Case 18: VIP

40 Years old Female Receive treatment of TB for one year which was P.A.S. + I.N.H., She took her drugs regularly and improved. Later on, She got odd behavior and condition deterioration till she became confused, unsteadiness in cooperative, apathetic and amnesia to recent evnts, no history of head trauma (odd behavior = frontal lobe lesion) On Examination: BP: 110/70 mmhg, Temp: 37 C, Pulse 70/min Regular, Chest & Heart: Normal, CNS: normal Investigations:, Ca: normal, F.B.S.: 110 mg%, CXR: Healed old Lesion

A- Give 4 Possible Causes

1- Presenile Dementia 2- I.N.H. Toxicity: Perepheral Neuropathy + Dementia 3- TB Encephalopathy to Frontal Lobe (Commonest) 4- Very Slow Viral Infection (after 30 y) as a result of old life attenuated vaccine of measles (Ex. Jakop Disease)

B- Investigations Needed
1- CT Scan Brain 2- Fundus Examination 3- CSF Examination & Culture 4- Tuberculine Test 5- Tumor Markers ___________________________________________________________________

Case 19:
65 years old female admitted with 4 days history of vomiting, diarrhea & upper abdominal pain. She had recurrent loss of weight & lethargy On Examination: Dark skin but pale, Vitiligo, Dehydrated, Rapid Weak Pulse, Generalized Abdominal Tenderness Investigations: Hb 14 gm%, WBCs 18000/mm3, Na 137 meq/L, K 8.8 meq/L (High), HCo3 8 mmol/L, FBS 53.3 mmol/L (n=5.6) (High), Urea 32 mmol/L (High), S. Amylase normal, Abdominal x-ray: gas under diaphragm, ECG: peak T-wave

A- What is Your Diagnosis ?

1Autoimmune Pancreatitis: Commonest -With: Pancreatitis abdominal pain, Hyperosmolar DM with high FBS, Dehydration, Loss of Weight, no Jaundice, no History of Cholecystitis in Chronic Pancreatitis, Normal S. Amylase Hyperosmolar Diabetes Mellitus: -With: Dehydration + High S. Urea, FBS is High, low HCo3, High Potassium -Against: Vitiligo, Rapid Weak Pulse Perforated Vessels: -With: Gas under Diaphragm, Leucocytosis, Generalized Abdominal Tenderness -Against: Vitiligo, Vomiting, Diarrhea, High FBS, High Urea & K Ruptured Amoebic Hepatic Abscess -< Peritonitis + Uremia: Gastroenteritis:

2-

3-

45-

B- What Would be 4 Most Useful Investigations ?

1234CT Scan Abdomen Serum Lipase Again TSR, Anti ANA Investigations for Other Associated Autoimmune Diseases

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Case 20:
20 years old female patient came to Causality department with swollen upper and lower lips, swelling spread to involve the whole face and neck associated with tightness in her throat. Over the past 3 years she had intermittent localizated swelling on her upper arms & lower legs lasting for 2 or 3 days. Two years ago she got abdominal pain & appendicectomy was suspected but at operation a normal appendix was found NB: DD of normal appendix pain is FMF, Salpingitis On Examination: Non-pitting edema of face & neck, swollen lips & closed eyes, CVS, Chest & GIT are normal, Urine analysis was normal NB: Angioedema is one of Immunological Emergencies Causing Anaphylaxis: Type I, Type II Type I: Wheel (Hypersensitivity skin reaction), Bronchospasm, Low C1 Levels Type II: Normal C1 Levels Both Types Present in Second to Fourth Decades

A- What is Your Diagnosis & Other Possible Diagnoses?

1Angioneurotic Edema: Commonest -With: Familial, Idiopathic, Swollen Lips, Abdominal Pain, Intestinal Edema, Anaphylaxis (Main Criteria of Diagnosis) Other Criteria: Abdominal Ischemia, FMF, Angioneurotic Edema, Epilepsy (Petit-mal) (Can Explain Abdominal Pain but not to Diagnose this case) Familial Mediterranean Fever Myxedema (Generalized non-pitting edema)

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B- What Was The Cause of Her Abdominal Pain 2 y. Ago?

Angioneurotic Edema Causing Intestinal Edema & Abdominal Pain

C- What is The Immediate Management of this Patient?

Investigations: C1 Esterase Inhibitor is Diagnostic for Angioneurotic Edema Part of Complement System Treatment: 1- Adrenaline IM Injection (not IV due to severe vasoconstriction) 2- Steroids IV 3- Antihistamines