General Medicine Case Studies
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Transcript of General Medicine Case Studies
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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.
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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?
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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.
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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?
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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.
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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.
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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.
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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.
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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.
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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
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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 ?
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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
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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%
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Urine : urobilinogen +ve , bilirubin +ve
1. give 6 possible causes for her jaundice
2. What 6 immediate investigations areindicated?
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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
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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?
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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.
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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?
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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.
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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.
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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
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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
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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 ?
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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
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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
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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.
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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
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1. Give 4 further investigations
2. Give 2 possible diagnosis
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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.
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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
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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
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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
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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
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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