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This patient presented with classic symptoms of Gastroesophageal Reflux Disease (GERD). Gastro-oesophageal reflux disease is a condition in which the reflux of gastric contents into the oesophagus provokes symptoms or complications and impairs quality of life. Typical symptoms of gastro-oesophageal reflux disease are heartburn and regurgitation. The pathogenesis of gastro-oesophageal reflux disease is multifactorial, involving transient lower esophageal sphincter relaxations (i.e failure of the inferior esophageal sphincter) and other lower esophageal sphincter pressure abnormalities. As a result, reflux of acid, bile, pepsin and pancreatic enzymes occurs, leading to esophageal mucosal injury as in this case Endoesophagitis. And the Esophagogastroduodenoscopy done confirms Endoesopahgitis as well.
H. pylori infection, Hypergastrinemia and Hypersecretion of hydrochloric acid can cause gastritis, gastric ulcer primarily but can also cause reflux disease if the lower or inferior esophageal sphincter is weak or relaxed.
Duodeno-gastric reflux - Duodenum to Stomach.
Amiodarone is a class III antiarrhythmic medication - potassium channel blockers. Amiodarone is a potent antiarrhythmic agent that is used to treat ventricular arrhythmias and atrial fibrillation. The drug prevents the recurrence of life-threatening ventricular arrhythmias and produces a modest reduction of sudden deaths in high-risk patients. Amiodarone is more effective than sotalol or propafenone in preventing recurrent atrial fibrillation in patients for whom a rhythm-control strategy is chosen.
Flecainide, Encainide, Moracizine are Class IC antiarrhythmic medication - Sodium channel blocker, commonly used only as a last resort in refractory Ventricular tachycardia. Digoxin is a cardiac glycoside that blocks Na+/K+ ATPase activity and improves contractility of the myocardium in heart failure. However, it can also be used in conditions such as Atrial Fibrillation.
This patient with ST segment elevation in leads II, III, aVF on ECG that also had an attack of retrosternal pain is definitely a case of STEMI - ST elevation Myocardial Infarction. With a blood pressure of 70/40mmHg (severe hypotension), the condition has deteriorated to a case of shock and in this case, it has a cardiac origin, therefore, it is a cardiogenic shock.
There is no arrhythmia recorded on ECG (no Atrial flutter or fibrillation, ventricular tachycardia or fibrillation), so it will be wrong to tag this an Arrhythmogenic shock. Perforated gastric ulcers can present with excessive bleeding and even result in shock but the patient will also present with hematemesis or melena and epigastric pain. Acute pericarditis can present with retrosternal pain but not likely to have shock. Acute pancreatitis will present with diarrhea, indigestion, epigastric belt-like pain radiating to the back, and it is unlikely for a patient with pancreatitis to have retrosternal pain and shock with the listed ECG findings.
Beta blockers (drugs ending with the suffix ‘lol’ e.g. Metoprolol, propranolol, labetalol) can be used as antiarrhythmic drugs (treat arrhythmias like Atrial fibrillation). They belong to class II of the antiarrhythmic medications. They can also be used in hypertensive conditions. Beta 1 receptors are present in the heart and when a Beta blocker is deplored, it can reduce the heart rate thereby reducing the cardiac output and contractility. They can also reduce the transmission of impulses through the AV node which makes them useful as antiarrhythmic agents.
Angiotensin Converting Enzyme Inhibitors (ACEI) inhibit the conversion of Angiotensin I to Angiotensin II thereby inhibiting the vasoconstrictive properties of Angiotensin II. This makes them very useful as antihypertensives.
In this case, the question is interested in how to prevent heart failure and a combination of Beta blockers and ACE inhibitors are the most effective as they both reduce blood pressure and workload on the heart. They reduce both the preload and afterload of the heart which will prevent ventricular remodelling in the long run.
Cardiac glycosides tend to increase heart contractility and in the long run, this increase in workload can lead to hypertrophy. Diuretics can reduce the preload but not effectively reduce the afterload.
First heart sound - Mitral and Tricuspid valve
Second heart sound - Aortic and Pulmonic valve
Closure of these valves during cardiac cycle produces the sound.
The second heart sound can have a physiologic splitting i.e. the aortic valve closes just before the pulmonic valve. This can occur when there is more blood flow through the pulmonic valve for example during inspiration there is increased blood return to the right side of the heart via the Superior vena cava and Inferior vena cava. This increased blood volume takes a longer time to pass through the pulmonic valve and this causes a slight delay - the aortic valve closes just before the pulmonic valve causing a physiologic splitting of S2.
Also, splitting of the second heart sound is commonly seen in Atrial Septal Defect, Pulmonic valve stenosis or right bundle branch block. In Atrial Septal Defect, there is a left to right shunt. Blood from the left atrium moves to the right atrium when they contract and this increases the blood volume in the right side of the heart. This increased blood volume takes longer to pass through the pulmonic valve. Thus, producing a split in the second heart sound.
Open Ductus Arteriosus will produce a continuous machine-like murmur throughout systole (heart contraction) and diastole (heart relaxation). Mitral insufficiency will produce a systolic murmur (holosystolic - throughout systole). Aortic stenosis will produce a bruit or murmur beyond the point of the stenosis. None of these other conditions produces a splitting of the second heart sound.
Status epilepticus is said to occur when a seizure lasts too long or when seizures occur close together and the person doesn't recover between seizures. Over the last several decades, the length of seizure that is considered as status epilepticus has shortened. Years ago, a seizure needed to last longer than 30 minutes to be considered status epilepticus. In the last few years, it is now defined as any seizure greater than 5 minutes. This makes sense because most seizures do not last longer than 2 minutes. Very long seizures (i.e., status epilepticus) are dangerous and even increase the chance of death.
Status epilepticus requires emergency treatment by trained medical personnel in a hospital setting. This situation can be life-threatening and getting treatment started fast is vital.
Medical treatment needs to be started as soon as possible. Oxygen and other support for breathing, intravenous fluids (fluid given into a blood vessel), and emergency medications are needed.
Continuous EEG (electroencephalogram) monitoring may be needed to monitor the seizures and how a person responds to treatment.
At times, medicines called anesthetics are used in the hospital to put a person into a coma to stop the seizures. - This will definitely be done in the Intensive Care Unit (ICU).
Neuroleptics, also known as antipsychotic medications, are used to treat and manage symptoms of many psychiatric disorders. They fall into two classes: first-generation or "typical" antipsychotics and second-generation or "atypical" antipsychotics." They are Dopamine D2 receptor antagonists. Antipsychotics are drugs that have a specific sedative effect, and which improve the attitude and calm the behavior of psychotic patients.
Typical antipsychotics: Haloperidol, Chlorpromazine
Atypical antipsychotics: Risperidone, Clozapine, Aripiprazole
Neuroleptic drugs are beneficial for the management of behavioral disorders. They are also associated with sedative effects, weight gain, or anticholinergic activity.
Bipolar disorder: a manic episode and depressed mood. For treatment of Bipolar disorders: Lithium, Valproic acid, Lamotrigine, Carbamazepine, and Atypical antipsychotics. This patient is currently having a manic episode and it's best to use a Neuroleptic (antipsychotic) with sedative effect to calm the patient down and to sleep.
A manic episode requires 3 or more of the following:
Decreased need for sleep
Impulsivity/Indiscretion: seeks pleasure without regard to consequences including sexual pleasure
Talkativeness or pressured speech
Grandiosity: inflated self esteem
Flight of ideas: racing thoughts
Increased goal oriented activity/psychomotor agitation
Antidepressants are used for Major Depressive Disorders; Tranquilizers are used for General Anxiety Disorder or Panic attacks.
There are some characteristics in a urine examination that suggest a diagnosis of renal Tuberculosis, such as acid pH, leukocyturia and/or hematuria, associated with negative urine culture for the usual bacteria that causes urinary tract infection (bacteria were not found on conventional media).
Points worthy of note from the Urine test result: acid reaction, leukocyturia and after inoculation on conventional media, bacteriuria were not found.
Now, Mycobacterium tuberculosis is acid fast due to the presence of Mycolic acid, so they will produce an acid reaction. There is increased lymphocytes (leukocyturia) with M.tuberculosis and viral infection (Neutrophils will increase with bacteria - Neutrophilia). Also, M. tuberculosis will not grow on conventional media and they stain poorly with Gram staining because their cell wall has high lipid content. To detect M. tuberculosis, Ziehl-Neelsen stain (Carbol fuchsin) is used instead.
Nechiporenko: This method helps to determine the amount of cellular elements (WBC, RBC and casts) in 1 ml of urine.
Zimnitsky's test characterize the concentrating and excretory ability of the kidney.
Daily proteinuria monitoring will give information about the extent of nephrotic syndrome or any other nephropathy like hypertensive nephropathy.
Isotope renography is an imaging technique that’s used to check kidney function.
Vegetarian diets are dietary patterns that are devoid of all flesh foods but may include egg or dairy products. Vegetarians have lower incidences of several health conditions including ischemic heart disease, total incidence of cancer, and type 2 diabetes. Despite these advantages, vegetarians also are at a high risk of a deficiency of some nutrients, such as vitamin B12 and iron.
This patient with malnutrition also complained about smell and taste distortion. Loss of smell and/or taste has been linked to inadequate nutritional intake, reduced social pleasure, and decreased psychological well-being.
Anemia is defined by reduced hemoglobin level or the erythrocytes volume in the circulation. Sideropenic anemia is a hypochromic, microcytic anemia caused by insufficient iron level in the body. This is the most common anemia.
Patients with Iron deficiency often manifest Pica. Pica is an unusual craving for and ingestion of either edible or inedible substances. It seems to be strongly associated with iron deficiency anemia, and in the majority of cases the unusual eating and chewing behavior disappears upon iron supplementation.
Patients with the diagnosis of sideropenic anemia are recommended to take iron supplements. By changing eating habits we can maximize iron input into our organism and prevent sideropenic anemia.
One of the most common complications occurring post-infarction is a ventricular aneurysm. Almost 85% to 90% of the ventricular aneurysms occur in the setting of acute anterior wall myocardial infarction. Left ventricular aneurysm is defined as a localized area of myocardium with abnormal outward bulging and deformation during systole and diastole. The natural course leading to the formation of a ventricular aneurysm involves a full-thickness (transmural) infarct that has been replaced by fibrous tissue. This inert portion cannot take part in the contraction and herniates outward during systole.
A week before presenting to the hospital, he had an acute myocardial infarction. A true left ventricular aneurysm following acute myocardial infarction can occur as early as within 48 hours or two weeks post-infarction.
Common symptoms associated with the ventricular aneurysm include: Fatigue; Shortness of breath (dyspnea); Chest pain; Palpitations; Syncope; Fluid retention causing swelling of ankles, feet, or abdomen (ascites); Stroke; Limb or visceral ischemia.
A recurrent myocardial infarction will present with the classic substernal chest pain or tightness. Acute pericarditis will produce chest pain as well and friction rub between the pericardial sheets. Pulmonary embolism is usually a complication of deep vein thrombosis (DVT).
Hypothermia is a severe condition in which the body temperature drops to an abnormally low level. It occurs when the body is unable to produce enough heat to counter the heat that it is losing. Under healthy conditions, the body maintains a relatively stable temperature of around 98.6˚F or 37˚C.
The following techniques can help treat hypothermia:
Passive external rewarming: This uses the individual’s heat-generating ability. It involves removing their cold, wet clothing, ideally replacing it with adequately insulated, dry clothing, and moving them to a warm environment.
Active external rewarming: This involves applying warming devices, such as hot-water bottles or warmed forced air, externally to truncal areas of the body. For example, the individual could hold a hot-water bottle under each arm.
Active core rewarming: This uses warmed, intravenous fluids to irrigate body cavities, including the thorax, peritoneum, stomach, and bladder. Other options include getting the individual to inhale warm, humidified air, or applying extracorporeal rewarming by using a heart-lung machine.
Do not give a person alcohol if they have signs of hypothermia, and avoid giving any drinks to an unconscious person.
From the vitals given, this patient is fairly stable except for the tachycardia (110bpm) and low body temperature, therefore passive warming will suffice. The patient was pulled out of the open water in a cold weather so removing the wet clothing, and replacing it with adequately insulated, dry clothing, and moving them to a warm environment will keep the patient warm.
Infective endocarditis (IE) is caused by damage to the endocardium of the heart followed by microbial, usually bacterial, colonization. It is an infection in the heart valves or endocardium. The endocardium is the lining of the interior surfaces of the chambers of the heart. Infective endocarditis disproportionately affects those with underlying structural heart disease and is increasingly associated with healthcare contact (the child was operated for congestive heart disease - CHD), particularly in patients who have intravascular prosthetic material.
Symptoms include: fever (most common); Janeway lesions (small, painless, erythematous lesions on palm or sole); new cardiac murmur; Roth spots (round white spots on retina surrounded by hemorrhage); Osler nodes (raised lesions on finger or toe pads due to immune complex deposition); and splinter hemorrhages on nail bed.
The patient presented with a blood pressure of 240/120mmHg which is markedly elevated. This increased blood pressure already led to the development of hypertrophy and left ventricular overload as stated in the question stem which are common complications associated with extremely high blood pressure. Initially, cardiac hypertrophies are usually compensatory mechanisms but if the blood pressure is not promptly and properly managed, it can become a full blown cardiac failure.
It is clear that this is a case of Complicated Hypertensive crisis. It is complicated with hypertrophy and pulmonary edema. The pulmonary edema is evidenced by the objective findings on auscultation of the lungs that revealed fine moist rales in the lower parts of the lungs.
This is not a case of acute myocardial infarction. Myocardial infarctions are often associated with severe substernal chest pain or tightness. There was no respiratory distress of any sort, so we can rule out both bronchial asthma and pneumonia.
The fact that the patient lost a lot of weight in a short period of time in the absence of any other pathology should signal a carcinogenic process. Key diagnostic features of this pathology include; blood in urine, presence of flank mass and pain accompanied with weight loss and high blood pressure. Note, most renal pathologies present with elevated blood pressure due to the Renin-Angiotensin-Aldosterone System (RAAS). The dilated veins of the spermatic cord and scrotum (varices) is due to disrupted venous blood flow caused by increased pressure from the obstruction caused by the tumour.
A patient with urolithiasis will also experience colicky (more like an attack with relieve period in between) flank pain, change in quantity of urine and can be differentiated by results from ultrasound which shows an obstruction in the ureter.
Glomerulonephritis often follows an upper respiratory tract infection 2-3weeks prior to presentation and can also present with a nephrotic syndrome (increased proteinuria accompanied by presence of edema). Pyelonephritis is inflammation of the kidney parenchyma which can be as a result of infection via an ascending or hematogenous pathway.
Laryngeal edema is a common complication in patients that have allergic predisposition. Symptoms of stridor, hoarseness, and tachypnea developed within 24 hours after contact with the offending agent which could be a bee sting, chemicals, animal dander, dust, pollen etc and subside within another 24 hours after inhalation therapy with heated aerosol mist.
The contact with chemicals led to the edematic reaction in the worker’s larynx. This is a possible irritation caused by chemical agents. Recall that the larynx is the voicebox; this is why the edematic reaction presents with symptoms such as stridor, voice hoarseness, barking cough etc.
Notice that the Blood pressure and heart rate are normal which indicates no case of hyperthyroidism or hypothyroidism. Recall that a goiter occurring in a hyperthyroid state is a Hyperthyroid goiter; one that occurs in a hypothyroid state is a hypothyroid goiter while a goiter that occurs in a normal physiologic state as it is in this patient is an Euthyroid goiter. This is a nodular form because on palpation, a mobile node was palpated.
The patient was admitted as a result of an allergic attack. From anamnesis, we find that these attacks mostly occurred while cleaning the room indicating that the causative factor is a household allergen. - Type I Hypersensitivity Reaction.
Gottron’s sign refers to erythematous macules/papules present on the elbows ( sometimes also on the knees) and are specific signs in diagnosis of dermatomyositis.
Dermatomyositis is a muscle disease, a long term inflammatory myopathy (muscle disorder) characterised by progressive proximal muscle weakness, Gottron papules and heliotrope rash. For diagnosis, a muscle biopsy is obtained and observed under the microscope; signs such as mononuclear antibodies, abnormal cell degeneration and regeneration etc are observed.
Sepsis refers to the body’s extreme response to infection. This patient most probably got infected during the surgical procedure; pyrexia, chills, tachycardia etc are key signs of the body’s reaction. To confirm the diagnosis and also find out the particular pathogen, a blood culture should be conducted.
Clotting time is the time required for a sample of blood to coagulate in vitro under standard conditions. The time taken for blood to clot mainly reflects the time required for the generation of thrombin. If the plasma concentration of prothrombin or of some of the other factors is low (or if the factor is absent, or functionally inactive), clotting time will be prolonged. The expected range for clotting time is 4-10 mins.
Clotting time involves the measurement of prothrombin time (PT) and activated partial thromboplastin time (aPTT). Prothrombin time assesses the extrinsic (factor VII) and common (factors X, V, II [prothrombin] and I [fibrinogen]) pathways, whereas aPTT assesses the intrinsic (prekallikrein, HMWK, and factors XII, XI, IX, and VIII) and common pathways.
From the blood analysis given, Macrocytes are present- this refers to irregular large Red Blood cells. Also the color index is elevated. The erythrocyte level is also very low ( norm- Female: 3.5 − 5.5 · 1012/L) - this indicates an anemia. The major causes of macrocytic anemia include Vitamin B12 deficiency, Vitamin B9 (Folic Acid) deficiency or medications such as antiretroviral drugs.
Symptoms include loss of appetite, brittle nails , pale skin, fatigue etc. To differentiate between B12 or Folic acid deficiency, Vit B12 deficiency is often associated with nervous system symptoms like paresthesias - subacute combined degeneration due to abnormal myelin synthesis. These nervous system symptoms are absent in Folic Acid Deficiencies.
With the symptoms listed in the question, and the presence of anemia and macrocytes - it is safe to say Vitamin B12 deficiency is the best choice.
Ascorbic acid or vitamin C deficiency will lead to scurvy, petechial bleeding or bruises are common in this case. Vitamin B1 deficiency will lead to the development of Beri-Beri.
From physical examination, we observe the presence of multiple injection marks on the patient’s body. This should raise a suspicion about an intravenous drug abuser and an infection with HIV. HIV is an immunosuppressive disease and patients suffering from this disease are prone to having opportunistic infections. For diagnosis of HIV infection, HIV antibodies are found in serum or saliva via ELISA test ( Enzyme linked Immunosorbent assay) and is usually confirmed by a western blot test.
Delta-aminolevulinic acid dehydratase is an enzyme necessary for the synthesis of heme. In lead poisoning, this enzyme is inhibited leading to anemia and an increased delta aminolevulinic acid content in urine. N/B a high reticulocyte number means an increase in RBC production ( new cells) and is observed in cases such as bleeding, high altitude or anemia. The above patient presents with signs of asthenic vegetative syndrome coupled with the above stated reasons confirming a case of lead poisoning.
Post-thrombotic syndrome refers to symptoms and signs of chronic venous insufficiency that develop following deep vein thrombosis (DVT) and is a common, burdensome, and costly complication . The term "post-thrombotic" replaces the prior terminology "postphlebitic" syndrome. A combination of reflux due to valvular incompetence and venous hypertension due to thrombotic obstruction is thought to underlie the pathophysiology of post-thrombotic syndrome . Symptoms and signs of post-thrombotic syndrome may include leg pain, leg heaviness, vein dilation, edema, skin pigmentation, and venous ulcers.
Deep vein thrombosis occurs when a blood clot forms in a deep vein usually in the thigh and lower leg. It presents with pain, warmth and tenderness of the affected area.
Acute arterial thrombosis occurs after an endovascular procedure results of the erosion or rupture of atherosclerotic plaque and/or distal embolization (DE). Both occurrences activate the coagulation and platelet systems, resulting in the occlusion of the artery by a thrombus.
The patient experiences an enlarged thyroid gland, tachycardia, loss of weight and exophthalmos - these symptoms are consistent with Hyperthyroidism ( thyrotoxicosis). For treatment: Mercazolil (thiamazole) is administered. Propranolol is a beta blocker and used in heart related issues while thyroxine is indicated for hypothyroidism.
This patient has a case of acute Pancreatitis. Recall that the pancreas has both endocrine and exocrine functions; for the exocrine part, it produces enzymes that aid in digestion such as amylase, lipase, trypsin. Absence of these enzymes will lead to symptoms such as steatorrhea (fats in feces), creatorrhea (undigested muscles in feces) etc. Panzinorm Forte is a combination of digestive enzymes. These enzymes are normally produced by the pancreas and are important for digesting fats, proteins, and sugars.
Panzinorm Forte is used to replace digestive enzymes when the body does not have enough of its own. Certain medical conditions can cause this lack of enzymes, such as cystic fibrosis, pancreatitis, pancreatic cancer, or pancreas surgery.
Panzinorm Forte may also be used to treat a condition called steatorrhea (loose, fatty stools).
Pirenzepine is an M1 selective antagonist used in treatment of peptic ulcer ( it reduces gastric acid secretion and muscle spasm). Contrykal is a protease inhibitor and is used in reducing blood loss in surgical procedures. Drotaverine is an antispasmodic drug used for cervical dilation in childbirth
Generally, persons at high risk for developing TB disease fall into two categories:
Persons who have been recently infected with TB bacteria
Persons with medical conditions that weaken the immune system
Persons in the second group include individuals with the following diseases; HIV infection (the virus that causes AIDS), Substance abuse, Silicosis, Diabetes mellitus, Severe kidney disease, Low body weight, Organ transplants, Head and neck cancer, Medical treatments such as corticosteroids or organ transplant, Specialized treatment for rheumatoid arthritis or Crohn’s disease.
Pheochromocytoma is a tumor that affects the chromaffin cells of the adrenal medulla. It leads to the increased production of catecholamines ( epinephrine and norepinephrine) which have vasoconstrictive effects leading to hypertension. Amongst the listed drugs, Phentolamine which is a non-selective alpha adrenergic receptor blocker is used in the management of hypertensive emergencies majorly due to pheochromocytoma. This drug has a vasodilating effect.
Pipolphen ( promethazine) is an antihistamine and is used in the treatment of allergic reactions, motion sickness, anaphylaxis etc. Mesaton is a decongestant and a vasopressor.
From the results of physical examination and biochemical analysis, we can conclude that this patient is having a urinary tract infection ( UTI) most likely of bacterial origin. From the groups of antibiotics listed below, Ciprofloxacin is the best of choice because of its high bacteriological and clinical cure rates as well as low resistance rate from bacteria that cause UTIs.
This patient is experiencing a subarachnoid hemorrhage (bleeding into the subarachnoid space). From the list of drug groups, anticoagulants (against coagulation), antiaggregants (against aggregation) and fibrinolytics ( breakdown fibrin) will worsen the current situation if administered. A coagulant will help in the management of the hemorrhagic situation.
The following types of chronic gastritis include;
Type A is caused by your immune system destroying stomach cells. And it can increase your risk of vitamin deficiencies, anemia, and cancer.
Type B, the most common type, is caused by Helicobacter pylori bacteria, and can cause stomach ulcers, intestinal ulcers, and cancer.
Type C is caused by chemical irritants like nonsteroidal anti-inflammatory drugs (NSAIDs), alcohol, or bile. And it can also cause stomach lining erosion and bleeding.
Observe that on examination, free HCL is absent and results from endoscopy and microscopy indicate the gastric cells have been destroyed - this occurs in Type A gastritis.
In menetrier's disease, we see an overgrowth of gastric cells ( foveola) found in the gastric lining which leads to the presence of large gastric folds.
From the description of the above patient, we can deduce that the issue is more psychological/mental than physical. This can be proven by the fact that all diagnostic procedures are without any pathological changes. Note that the problem was resolved when the patient was prescribed Valocordin (corvalol) a tranquilizer indicated for neuroses. Since it is a mental issue, the blood formula will show no changes.
Osteoarthritis is the inflammation of the joint that occurs due to continuous exertion of that area ( wear and tear); unlike Rheumatoid arthritis that is of autoimmune origin. Observe that the presentation of this patient has been observed for the last 5 years, is one sided and worsens on exertion- these facts help differential from rheumatoid arthritis that has a rapid onset ( weeks- months), occurs symmetrically and improves upon usage of the affected area.
Reactive arthritis is an autoimmune condition that develops in response to an infection in another part of the body. Coming into contact with bacteria and developing an infection can trigger reactive arthritis. It has symptoms similar to various other conditions collectively known as "arthritis,". It is caused by another infection and is thus "reactive". The symptoms of reactive arthritis very often include a combination of three seemingly unlinked symptoms—an inflammatory arthritis of large joints, inflammation of the eyes (conjunctivitis and uveitis), and urethritis. A useful mnemonic is "the patient can't see, can't pee and can't bend the knee" or "the patient can't see, can't pee and can't climb a tree". Also known as Reiter’s syndrome.
The woman not only shows signs of hypertension but also presents with changes relating to body metabolic activities (tremors, tachycardia, dizziness, palpitations, sweating - these are signs relating to stress ( caused by the release of stress hormones i.e. catecholamines). Pheochromocytoma is a tumor of the adrenal gland, it is characterised by the increased production of catecholamines ( adrenaline, noradrenaline) coupled with stress symptoms. Essential hypertension is also called primary hypertension- a form of hypertension with no underlying disease as its cause. Preeclampsia is a pregnancy-associated hypertension coupled with other signs. Primary hyperaldosteronism or Conn’s disease is also associated with the above stated signs , its other signs may include kidney related problems, excessive urination, low potassium content, flank pain etc.
Note that vasopressin is the most potent vasoconstrictor of internal organs, it decreases blood flow to all abdominal organs, decreasing venous inflow into the portal veins and portal pressure. Vasopressin always should be accompanied by intravenous nitroglycerin to maintain a systolic blood pressure of greater than 90 mm Hg.
Reserpine is an antihypertensive drug and acts by reducing the amount of norepinephrine. Calcium gluconate is used in the treatment of magnesium toxicity, hypocalcemia and hyperkalemia.
Botulism is an illness caused by Botulinum toxin , a toxin produced by Clostridium Botulinum ( a gram positive, spore forming, anaerobic bacteria). Foodborne botulism is gotten from eating infected food especially canned food. Symptoms include; disturbed vision (diplopia), flaccid paralysis, dysphagia, dyspnea etc. It is treated with Botulinum antitoxin.
Systemic scleroderma is a chronic multisystem disorder of unknown etiology characterized clinically by thickening of the skin caused by accumulation of connective tissue and by involvement of visceral organs, including the gastrointestinal tract, lungs, heart, and kidneys. Common symptoms include Raynaud phenomenon, polyarthralgia, dysphagia, heartburn, and swelling and eventually skin tightening and contractures of the fingers.
In Periarteritis nodosa (PAN), small and medium sized vessels are inflamed leading to disruption in major organs such as nerves, intestinal tract, heart, and joints.
Systemic lupus erythematosus is characterised by a malar/ butterfly rash.
From anamnesis, we understand that the patient has just returned from Africa , this should prompt the idea of a malarial infection. Malaria is caused by a plasmodium infection (P.vivax, P.falciparum, P.malariae, P.ovale. In its life cycle, various stages are involved ( see image).
Recall that ammonia is converted via the urea or ornithine cycle into urea; this conversion takes place in the mitochondria of liver cells. This patient has liver cirrhosis which means that liver cells are damaged; the presented symptom of convulsions and mental confusion are due to the fact that ammonia can cross the blood brain barrier thereby affecting the brain’s function. To confirm this, the level of ammonia in the patient’s blood should be checked.
Alpha fetoprotein is a tumor marker that indicates tumors related to the liver, ovaries, testes etc. In embryology, it is elevated in cases of neonatal defects such as down’s syndrome and spina bifida.
So basically, we need to differentiate Rheumatoid Arthritis (RA) and Osteoarthritis (OA) so that we can arrive at the correct answer.
RA: autoimmune, which erodes articulated cartilage and bone. The inflammatory cells and cytokines then induce pannus (proliferative granulation tissue) formation, deep usurations.
Associated with pain, swelling and morning stiffness, lasting >1hr and the pain improves with use.
Joint findings: joint space narrowing; erosions; juxtaarticular osteopenia; soft tissue swelling; subchondral cysts
Involves Metacarpophalangeal joints; wrist; proximal interphalangeal joints. Does not affect distal interphalangeal joints on the hands
OA: mechanical wear and tear - it’s a degenerative joint disease.
Associated with Pain in weight bearing joints after use (i.e. at the end of the day), and the pain improves with rest.
Joint findings: joint space narrowing; osteophytes (bone spurs); subchondral sclerosis and cysts.
Involves distal interphalangeal joints on the hands (heberden nodes) and Proximal interphalangeal joints (Bouchard nodes); does not affect Metacarpophalangeal joints and wrist.
So let’s answer the question:
From the question stem - Radiocarpal (wrist joints); Proximal interphalangeal joints were affected with usurations.
These are clearly signs and symptoms of Rheumatoid Arthritis...
Notice that the question states ‘loss of consciousness without convulsions’ ‘ this rules out the option of an epileptic attact which is characterised by seizures that sometimes lead to loss of consciousness. Syncope is simply termed fainting; it occurs as a result of reduced blood flow to the brain; notice that the blood pressure is very low- this leads to a reduced blood flow to major organs of the body especially the brain. This is a leading mechanism for the development of syncope.
Hysterical neurosis is a neurologic disorder characterised by sensory and motor disturbances as well as emotional outbursts and breakdown.
Cataract is the opacification (clouding) of the lens which leads to a decrease in vision (visual acuity). The visual acuity in adults is 60/60 or 6/6 which equals 1. Notice that on examination, the cornea, anterior chamber , iris showed no pathology but there are areas with opacities and vacuoles on the crystalline lens that indicates the presence of cataract. Also notice the irregularities in the pupil ( it is pathologic). A complicated cataract is one accompanied by or caused by an intraocular pathology - in this case the patient’s cataract is accompanied by the defect in the pupil.
Note that senile cataract is age-related ( progressive clouding and thickening of the lens as one gets older).
Tetanic cataract is mostly seen in individuals with hypoglycemia especially after a thyroidectomy. Also referred to as hypocalcemic cataract.
From anamnesis, this patient presents with fever, pain, a sign of pericarditis- inflammation of the heart pericardium ( the presence of pericardial rub on auscultation) etc. From the listed options of medications to be given, fibrinolytics and coagulants should be given in the case of a clot formation, Nitrates and nitrites are vasodilators; they may relieve the pain associated with Ischemic heart disease but have no effect on fever and the inflammatory process. Antibiotics would have been highly considered but notice that from blood analysis, the WBC is just a little bit above normal while the ESR is within normal range. Recall that glucocorticoids have anti-inflammatory, immunosuppressive and antipyretic effects and in this case will be best suited amongst the available options.
While considering the medication for hypertension, we should put into consideration that this patient is experiencing hypokalemia ( low level of potassium in the blood)(Potassium, plasma 3.5-5.0 mmol/L is the normal range) ; note that the alkaline urine reaction is as a result of an increased excretion of potassium in the urine. So while administering the antihypertensive medication, we should also try to reduce or stop the further excretion of potassium. In this case, the best possible option is spironolactone which is a Potassium sparing diuretic (causes urine excretion but prevents potassium removal).
Propranolol ( beta blocker) and enalapril ( sodium channel blocker) are anti hypertensive drugs too but they don't prevent the excretion of potassium. Hydrochlorothiazide is a thiazide diuretic, it reduces sodium reabsorption in the distal convoluted tubule and keeps calcium in the blood.
On a normal ECG, the P wave represents atrial depolarization (contraction), QRS complex- ventricular depolarization (contraction) and T wave - ventricular repolarization (relaxation). The sinus atrial node is the natural pacemaker of the heart; it produces electrical impulses at the rate of 60-70 beats per minute.
In this patient, at certain periods, she experiences fibrillations while at other times, she experiences bradycardia. Coupled with results from the ECG (complete dissociation of P wave and QRST complex), we can conclude that this patient has a defective pacemaker. An artificial pacemaker will be the most effective treatment for this patient. Calcium antagonists (blockers) will only be useful in periods of tachyarrhythmia but are contraindicated in bradycardia.
This patient presents with difficulty in breathing, cough, no sputum production, and is cyanotic - these are signs that indicate an asthmatic attack. But also notice that salbutamol has no effect on his current situation (recall that salbutamol is beta-2 adrenergic receptor agonist usually in the form of inhalers; they cause relaxation - bronchodilation of airway smooth muscles). The current state of the patient coupled with unresponsiveness to the medication indicates a state known as Status Asthmaticus. It is defined as a state of severe asthmatic attack which does not respond to conventional treatment.
N/B the fact that this patient does not respond to salbutamol rules out the option of bronchial asthma (moderate gravity) and cardiac asthma is usually a complication of heart failure.
Different blood groups present with different antigens and antibodies.
Group I (O) presents with anti A and anti B antibodies but no antigen.
Group II (A) presents with anti B antibody and A-antigen.
Group III (B) presents with anti A antibody and B- antigen
Group IV (AV) presents with no antibodies and antigen A and antigen B. Note that the presented antigen determines the blood group.
In terms of compatibility, Group IV (AB) is a universal recipient because it lacks antibodies, while Group I (O) is a universal donor because it lacks antigens; Group II (A) can receive from A and O but can donate to A and AB; Group III(B) can receive from B and O but can donate to B and AB.
From the question stem, a positive reaction with Group II (A) and III(B) shows that anti A and B antibodies are present in the sample blood (indicating group I (O)) - but also notice that when the blood sample was tested with group I (O) and IV (AB), a negative reaction occurs. This proves that the standard sera used in testing is faulty and is currently giving inaccurate results because there should be a positive reaction with Blood Group AB (IV) - it has both A and B antigen.
A felon (a form of whitlow) is an acute and painful inflammation of the deeper tissues of the fingers or toes. It is characterised by the presence of an abscess in the affected area. Paronychia is a bacterial or fungal infection of the nail (where the nail meets the skin). Pandactilitis is an inflammation of the entire finger or toe joints, in this case, the inflamed digits look like sausages.
Presence of pain in the right hypochondrium should indicate that the problem lies either in the liver, gallbladder or bile ducts. Coupled with an increased level of bilirubin, antibodies against smooth muscles were found from biochemical analysis. Note that Smooth muscles antibodies are found in autoimmune type hepatitis. This is because certain liver diseases such as hepatitis and cirrhosis trigger the body to form antibodies against smooth muscle. Other antibodies that can be seen in autoimmune hepatitis include Antinuclear antibodies, Anti-actin antibodies, Anti-soluble liver antigen/liver pancreas (anti-SLA/LP) antibodies. Other antibodies may be present, even when the anti-smooth muscle antibodies are absent.
Recall that the cerebral cortex is made up of different lobes, sulci and gyri that act as centres for various functions for example the occipital lobe for vision. The cerebral cortex can further be divided into brodmann's area with each area having a specific function eg area 44 & 45 (broca’s area) - for motor activities in speech production etc. This patient presents with temporal disorientation, problems with understanding questions, repetition of syllables (logoclonia), long term memory defects- these signs are mostly due to a defect in the Temporal lobe ( responsible for long term memory, processing auditory and visual sensory input, language recognition and formation of new memories). She also has defects with the cognitive function - can't clean or cook, fasten her button, confused etc.
Note that from anamnesis, since this patient does not have any underlying disease that can lead to an atherosclerotic formation, that option is ruled out. The above stated symptoms are indicative of a global cortex dysfunction affecting a wide area of the cerebral cortex and most likely due to the atrophy of the cerebral cortex.
Herpes simplex viruses are enveloped double stranded linear viruses. HSV-1 is also known as oral herpes ( gingivostomatitis, keratoconjunctivitis etc) while HSV-2 is known as genital or neonatal herpes. The clinical presentation of genital herpes include pain, itching, dysuria, vaginal and urethral discharge, tender lymphadenopathy, appearance of herpes vesicles on the external genitalia, labia majora, labia minora, vaginal vestibule - for women and glans penis, the prepuce, the shaft of the penis, and sometimes on the scrotum, thighs, and buttocks- for men.
Primary syphilis usually presents with a localized painless hard chancre on the genitals.
Cytomegalovirus is also known as human herpes virus-5, it is usually seen in immunocompromised patients and infected cells have characteristic ‘ owl's eye’ intranuclear inclusions.
Leukemias are malignant neoplasms of the hematopoietic stem cells characterized by diffuse replacement of the bone marrow by neoplastic cells.
From the question stem, using the full blood count, we can denote that there is Leukemia due to the presence of immature blast cells. To distinguish between Acute and Chronic leukemia, the blast count is always very important. Blasts are immature white blood cells.
In chronic Leukemia, the blood and bone marrow contain less than 10% blasts (blast - 2%). In Acute leukemia, blasts are usually more than 20%. Using the lab values given in the question, we have 87% of blast cells, which makes it Acute Leukemia..
Iron deficiency anaemia is a condition where a lack of iron in the body leads to a reduction in the number of red blood cells. Iron is used to produce red blood cells, which help store and carry oxygen in the blood. If you have fewer red blood cells than is normal, your organs and tissues won't get as much oxygen as they usually would. Causes include blood loss ( bleeding, menorrhagia etc), poor diet, malabsorption and hookworms. Key findings include; koilonychia (spoon shaped, brittle nails), atrophic glossitis (loss of filiform papillae on the tongue), angular cheilitis (inflammation of mouth corners) etc. Note that Anisocytosis refers to the presence of RBCs of various sizes while poikilocytosis refers to RBCs of various shapes - both findings are usually in Iron deficiency anemias.
Copper deficiency will present with signs such as difficulty in learning and forming memories, weak and brittle bones, difficulty walking, vision loss (Kayser–Fleischer ring in eyes).
Status epilepticus (SE) is a common, life-threatening neurologic disorder that is essentially an acute, prolonged epileptic crisis. Status epilepticus is defined as a continuous seizure lasting more than 30 min, or two or more seizures without full recovery of consciousness between any of them. Based on recent understanding of pathophysiology, it is now considered that any seizure that lasts more than 5 min probably needs to be treated as SE.
It can also be defined as a seizure that persists for a sufficient length of time or is repeated frequently enough that recovery between attacks does not occur. Therefore, the key phrase here is “recovery between attacks does not occur.” The question puts it this way - ‘between the seizures the patient did not come to waking consciousness.’
Prolonged Status epilepticus can lead to cardiac dysrhythmia, metabolic derangements, autonomic dysfunction, neurogenic pulmonary edema, hyperthermia, rhabdomyolysis, and pulmonary aspiration. Permanent neurologic damage can occur with prolonged SE.
From the blood analysis given, Macrocytes are present- this refers to irregular large Red Blood cells. Also the color index is elevated. The erythrocyte level is also very low (norm- Female: 3.5 − 5.5 · 1012/L) - this indicates an anemia . The major causes of macrocytic anemia include Vitamin B12 deficiency, Vitamin B9 (Folic Acid) deficiency or medications such as antiretroviral drugs.
Symptoms include loss of appetite, brittle nails , pale skin, fatigue etc. To differentiate between B12 or Folic acid deficiency, Vitamin B12 deficiency is often associated with nervous system symptoms like paresthesias - subacute combined degeneration due to abnormal myelin synthesis. These nervous system symptoms are absent in Folic Acid Deficiencies.
With the symptoms listed in the question, and the presence of anemia and macrocytes - it safe to say Vitamin B12 deficiency is the best choice.
Ascorbic acid or vitamin C deficiency will lead to scurvy, petechial bleeding or bruises are common in this case. Vitamin B1 deficiency will lead to the development of Beri-Beri. Iron deficiency will result in Anemia but macrocytes will be absent on the blood film, instead we will see microcytes.
This patient presents with decreased aldosterone (mineralocorticoid); cortisol (glucocorticoid); hyponatremia; hypotension - these are signs of adrenal insufficiency because aldosterone and cortisol are primarily produced in the Adrenal gland.
Adrenal crisis, also termed acute adrenal insufficiency is an acute life-threatening condition. It is considered one of the endocrine emergencies precipitated by an internal or external process in the setting of known or unknown lack of production of the adrenal hormone cortisol, the major glucocorticoid.
The adrenal gland\'s main function is to produce both mineralocorticoids and glucocorticoids. There are other hormones secreted by the adrenal glands including catecholamines and precursors of sex hormones. The adrenocorticotropic hormone (ACTH) is produced by the pituitary gland and its main function is to stimulate the cortisol release from the adrenal glands.
The main function of aldosterone is sodium retention and potassium secretion. The cortisol promotes gluconeogenesis, increases sensitivity to catecholamines, and regulates the immune system. If a patient with primary insufficiency has an adrenal crisis, they may be found to be hyponatremic in addition to having hypoglycemia and hypotension due to both aldosterone and cortisol deficiency, respectively. They also present with hyperpigmentation as a result of increased ACTH levels.
It is now clear that the best treatment is to administer hormones that have low levels - glucocorticoids (cortisol); mineralocorticoids (aldosterone) and a diet with high content of cooking salt to correct hyponatremia.
Neuroleptics, also known as antipsychotic medications, are used to treat and manage symptoms of many psychiatric disorders. They fall into two classes: first-generation or "typical" antipsychotics and second-generation or "atypical antipsychotics." They are Dopamine D2 receptor antagonists. Antipsychotics are drugs that have a specific sedative effect, and which improve the attitude and calm the behavior of psychotic patients.
This patient is currently having a manic episode and it\'s best to use a Neuroleptic (antipsychotic) with sedative effect to calm the patient down.
Antidepressants are used for Major Depressive Disorders; Tranquilizers are used for General Anxiety Disorder or Panic attacks. Mood stabilizers like Lithium, Valproic acid, Lamotrigine, Carbamazepine are commonly used in Bipolar disorders. Nootropics are used to enhance mental function not mania.
The above description is typical for Tinea (pityriasis) versicolor which is caused by malassezia spp. A yeast like fungus. It is characterised by areas of hypopigmentation ‘white spots’. Hyperpigmentation can also occur due to inflammatory response - ‘areas of brown spots .’ It differs from dermatophytes because it is less pruritic (itchy).
Basically, all the other options listed here are itchy, while Pityriasis versicolor is non-itchy.
Pityriasis rosea is a viral rash that resembles small oval red patches and are very itchy. Seborrheic dermatitis is a common skin disease that causes an itchy rash with flaky scales and mainly affects the scalp, face and trunk. Vitiligo is a condition that is associated with pathological destruction of melanocytes.
Forensic pathologists are essentially required to estimate the time since death (TSD) to assist in death investigation. The early post-mortem phase is most frequently estimated using the classical triad of post-mortem changes – rigor mortis, algor mortis and livor mortis.
Rigor mortis is the post-mortem stiffening of muscles, caused by the depletion of adenosine triphosphate (ATP) from the muscles.
Absence of spontaneous breathing, pulselessness or unconsciousness can be as a result of collapse (syncope) and not outright death. Absence of corneal reflexes is very possible and can be diagnosed in patients that are alive but with cranial nerve disorders (especially cranial nerve V and VII).
Delirium tremens also known as Alcohol withdrawal delirium is the most severe form of alcohol withdrawal symptoms. It is characterised by an altered mental status and hyperactivity of the autonomic nervous system. Remember from the question stem, this started a day after one of his drinking bouts.
Delirium tremens occurs in chronic alcohol abusers who abruptly discontinue alcohol use, often as early as 24 - 48 hours. Alcohol acts as a central nervous system depressant. It enhances the effect of inhibitory neurotransmitters while down-regulating excitatory neurotransmitters. Abrupt cessation of alcohol causes a decrease in the inhibitory actions of GABA neurotransmitter resulting in overactivity of the central nervous system.
The overactivity seen with alcohol withdrawal manifests as altered mental status, hallucinations (“may be killed”), anxiety, seizures, tremors, psychomotor agitation, insomnia etc.
Your thyroid produces thyroid hormone, which controls many activities in your body, including how fast you burn calories and how fast your heart beats. Diseases of the thyroid cause it to make either too much or too little of the hormone. Depending on how much or how little hormone your thyroid makes, you may often feel restless or tired, or you may lose or gain weight. Women are more likely than men to have thyroid diseases, especially right after pregnancy and after menopause.
Hypothyroidism is when your thyroid does not make enough thyroid hormones. It is also called underactive thyroid. This slows down many of your body's functions, like your metabolism. Signs and symptoms include the following: Feeling cold when other people do not; Constipation; weight gain, even though you are not eating more food; Feeling sad or depressed; Feeling very tired; Pale, dry skin; Dry, thinning hair; Slow heart rate (bradycardia); puffy face; hoarse voice; abnormal menstrual bleeding etc.
Note that the craniogram shows no pathology so we can rule out Hypothalamic-pituitary. Hypo-ovarian can present with amenorrhea, vaginal dryness, monophasic cycles etc but not with bradycardia or weight gain. Absence of abdominal striaes or skin hyperpigmentation and sometimes diabetes - rules out the option of cushing’s disease (hypercorticoidism).
The increased TSH levels seen in this patient implies an activation of the feedback mechanism signalling the body to produce more thyroid hormones; T3 and T4.
Potato juice helps eliminate gastric acidity thereby, relieving ulcer pain. Apple juice is rich in vitamin A and is recommended in individuals with poor sight, it also helps in reducing the risk of dementia in old individuals.
Delirium tremens also known as Alcohol withdrawal delirium is the most severe form of alcohol withdrawal, it is characterised by an altered mental status and hyperactivity of the autonomic nervous system. From the question stem, we observe that this patient is a chronic alcoholic and has been without alcohol for 2 days leading to the described symptoms.
Amentia: this is a rough obscured consciousness with incoherent thought, complete unavailability for contact, isolated deception of perception and signs of sudden physical exhaustion. Patients in amentia generally lie in spite of having chaotic excitements.
Oneiroid: it is also called dreamlike state and is defined by fantastic psychological suffering. It is characterized by ambivalent/contradictory speech, criminal action, senses global changing, catastrophe, and celebration simultaneously.
Herpes zoster is a viral disease that is caused by the Varicella-Zoster virus, it is characterized by inflammation of intervertebral or cranial nerves nodes and is shown up by a vesicular rash (with transparent exudate)on a skin along the nerves and symptoms of intoxication. The rash elements are macule - papule - vesicle - crust polymorphism which is often accompanied by hyperthermia.
Dermatitis herpetiformis (also known as ‘DH’ or Duhring disease) is a rare but persistent blistering skin condition related to coeliac disease. Dermatitis herpetiformis is characterised by extremely itchy bumps (prurigo papules) and blisters (vesicles), which arise on normal or reddened skin. They tend to be distributed symmetrically and are most often found on the scalp, shoulders, buttocks, elbows and knees.
As the blisters are so itchy, they are often immediately scratched, resulting in erosions and crusting. Older lesions may leave pale or dark marks (hypopigmentation and hyperpigmentation).
The pancreas plays a major role in digestion ( its exocrine function). It produces digestive enzymes such as; trypsin and chymotrypsinogen ( for protein digestion), Amylase (for carbohydrate digestion), lipase ( for breakdown of fats). In pathologies relating to the pancreas such as pancreatitis, this function is affected leading to a digestion and absorption issue. For example, due to a disruption in the release of lipase, fat breakdown is negatively affected leading to not enough absorption and its appearance in stool ( steatorrhea). Likewise a disruption in chymotrypsin and trypsin secretion will lead to an abnormal excretion of muscle fibres in faeces (creatorrhea).
Usually seen in individuals with serious liver diseases, Esophageal varices refers to enlarged or swollen veins on the lining of the esophagus. Most likely complications are severe internal bleeding, hypovolemic shock and cardiac arrest. Notice that this patient has decompensated cirrhosis of the liver ( the cause of these varices); an absence of neurological signs rules out the option of hepatic encephalopathy.
Intense pain in the right hypochondrium should signal the presence of a pathology in relation to the liver or gallbladder. This can be further proven by the presence of icteric skin and sclera ( due to the deposition of bilirubin on the skin and sclera). The results from palpation ( tenderness in right hypochondrium) and biochemical analysis ( increased bilirubin levels) helps confirm this. Cholangitis is an inflammation of the biliary system mostly as a result of bacterial infection. Of all the listed options, only cholangitis is in relation to gallbladder or liver pathology.
This is a classical case of Neurosyphilis. Neurosyphilis is a bacterial ( syphilitic) infection of the brain and spinal cord; it occurs on the background of a chronic syphilitic infection (notice that this patient has a long history of syphilis infection not properly treated).
Dementia is a brain related disorder characterized by progressive impairment of memory, thinking and behaviour that affects one’s everyday activities ( a decline in one’s mental and cognitive function that does not correspond to the age of the patient).
Lacunar dementia is also known as Binswanger disorder or Subcortical arteriosclerotic encephalopathy. Typically presents with Gait, urinary incontinence, parkinsonian features, pseudobulbar palsy etc.
Korsakoff’s ( amnestic ) syndrome is characterised by thiamine deficiency ( beri-beri) on the background of chronic alcoholism.
In Somnolentia, the individual experiences incomplete sleep/ drowsiness which resembles a state of drunkenness.
The results from the complement binding reaction is positive for Rickettsia Prowazekii which is the causative agent for Epidemic typhus. Epidemic typhus is an infectious disease transmitted via Body lice ( note that other variants of the typhus disease can be transmitted by fleas). It is characterised by fever, petechial rashes which begins on the trunk and spreads to the extremities, and flu-like symptoms. Note that for treatment, Doxycycline is the drug of choice.
Herpetic vesicular dermatitis (herpes simplex dermatitis) occurs as a result of an infection by HSV 1 ( human simplex virus 1) and is characterised by the presence of grouped vesicles ( blisters), erythematous in nature. These blisters are usually very painful and itchy. Notice that; From objective examination of this patient, erythematous grouped vesicles are found.
Dermatitis herpetiformis (duhring’s disease) is an autoimmune skin disease that targets those with gluten intolerance or celiac disease. People with celiac disease are unable to digest the gluten protein that is present in grains such as wheat, rye and barley. Itchy blisters and hives will form commonly on a person’s back or buttocks; this disorder is handled by removing all gluten containing products from a person\'s lifestyle. People with hypothyroidism, Sjogren’s disease or rheumatoid arthritis are also known to get this skin condition.
This patient has a history of allergy (asthmatic attacks); recall that an allergy is a type 1 hypersensitivity disorder - B cells are stimulated by CD4+TH2 cells which leads to the production of IgE antibodies against the trigger antigen. Recall that these IgE antibodies bind to specific receptors on mast cells and basophils. On further exposure to the same trigger ( allergen), these mast cells release mediators ( histamine, prostaglandins, leukotrienes etc). These mediators are responsible for the changes observed in allergic attacks.
Intalum inhalation (Cromolyn sodium) is a mast cell stabilizer. They block the early and late responses in asthmatic attacks, control inflammation in asthma and are used for prophylaxis in allergic asthma.
Berotec Inhalation (fenoterol) -β2 agonist; Atrovent Inhalation - Ipratropium (muscarinic antagonist).
Acute thrombophlebitis refers to the inflammation of a vein due to the formation of a blood clot (thrombus). Key findings include; pain, hyperemia , edema, tenderness and Veins being hard and cord-like.
Paravenous tissue necrosis is ruled out due to the absence of necrosis on examination; a phlegmon refers to the inflammation of soft tissue due to an infection and is characterised by the production of pus ( this helps rule out tissue phlegmon).
Subchondral sclerosis is a condition common in people with osteoarthritis. It refers to the hardening/ stiffening of the bone just below the cartilage. Note that “Chondra” is another word for cartilage, so subchondral means “beneath the cartilage.” “Sclerosis” means hardening. Subchondral sclerosis appears in the later stages of osteoarthritis, when there’s a degeneration of cartilage.
Deposition of urates (tophi)in the articular tissues will be seen in Gout while Hemarthroses refers to bleeding into the joint cavity.
Somatoform disorders - multiple, recurrent and frequent somatic complaints requiring medical attention without association with any physical disorder. The above patient’s heart ache is not related to any physical activity and occurs at a particular period of the year.
Hypochondriacal Disorder is characterized by a persistent preoccupation and a fear of developing or having one or more serious and progressive physical disorders. Physician physical examination does not reveal any disorder, but the fear and convictions persist despite the reassurance.
One major difference between Irritable bowel syndrome and inflammatory bowel disease is that intestinal mucosa is not affected in IBS while IBDs (Crohn’s disease and ulcerative colitis) have their mucosa affected.
Irritable bowel syndrome is an inflammatory bowel disease characterised by recurrent abdominal cramps/spasms (pain), change in form (consistency) and frequency of stool, constipation etc. . This condition is common in middle aged women and is associated with underlying conditions such as stress, anxiety, depression or a previous case of intestinal infection.
Notice that in this patient, on endoscopic examination, painful spasm occurred while intestinal mucosa is not changed- this is indicative of Irritable bowel syndrome.
In malabsorption syndrome, the small intestine is unable to absorb certain nutrients eg carbohydrates, proteins etc. can be caused by certain diseases such as celiac disease, lactose intolerance etc.
The key finding here is the erythema on the cheeks and bridge of nose which describes a malar/ butterfly rash classically seen in patients with Systemic lupus erythematosus.
SLE is a chronic inflammatory disease of unknown cause which can affect the skin, joints, kidneys, lungs, nervous system, serous membranes and/or other organs of the body. Distinct immunologic abnormalities, especially the production of a number of antinuclear antibodies, other signs include, arthralgia, myalgia, nephritis, systolic murmurs in about 30% of patients, dry pleurisy in the lungs etc. The dry pleurisy is characterised by an abnormal sound on auscultation called a pleural friction rub.
Rheumatic carditis and arthritis will be observe in a case of rheumatic fever ( prior infection by group A beta hemolytic streptococci infection)
Note that from anamnesis, the patient reported no cardiac problems. The heart rate revealed 72 beats per minute without pulse deficits - this finding debunks the claim of a clinically significant atrial fibrillation. Also take note that there are no signs of Heart failure therefore, this patient does not require any form of treatment.
This patient has a history of repeated renal colic over the past one year. Renal colic refers to a form of abdominal pain that occurs as a result of urinary stones blocking the urinary tract ( bladders, ureters, urethra). This kidney pathology can be supported by a positive pasternetsky’s sign ( costovertebral angle tenderness). One basic component excreted by the kidneys via urine is uric acid. Due to the blockage of the urinary tract, these products are not excreted and remain accumulated in the blood system. Amongst the listed options, An elevated uric acid level is the most helpful in putting a diagnosis.
Elevated rheumatoid factor is helpful in the diagnosis of autoimmune conditions such as rheumatoid arthritis, Sjogren's syndrome etc.
Since the patient complains about spontaneous bruises, bleeding gums, numerous hemorrhages of various time of origin, the blood platelet level should be checked, as it was not given in the blood count. Platelets/ thrombocytes help in blood clot formation.
Obliterating Endarteritis is also known as Buerger’s disease and vasculitis. The condition is thought to occur as a result of tobacco use and more common in males. The disease is characterized by inflammation and thrombosis of small and medium arteries of the legs and feet which recurs and progresses in stages. During the ischemic period, the veins of the lower leg are inflamed, skin has ulceration, and there is gangrene with intermittent claudication. During the nutritional disorder period there is persistent pain and muscle atrophy. During the necrosis period, the pain becomes worse as infection leads to the development of ulcers and gangrene. Pains usually persist; In addition, the patient usually complains of coldness and numbness. Burning sensations is another disturbing symptom.
Treatment usually has to do with smoking cessation.
Raynaud disease is a condition in which some areas of the body feel numb and cool in certain circumstances. In Raynaud's phenomenon, smaller arteries that supply blood to the skin constrict excessively in response to cold, limiting blood supply to the affected area. The fingers, toes, ears and tip of the nose are commonly involved and feel numb and cool in response to cold temperatures or stress.
Leriche Syndrome, also commonly referred to as aortoiliac occlusive disease, is a product of atherosclerosis affecting the distal abdominal aorta, iliac arteries, and femoral popliteal vessels. Its triad include; claudication, erectile dysfunction and decreased distal pulse.
Notice that this patient has tonic tension of the masticatory muscles and cannot open the mouth (TRISMUS); tension and twitching of the muscles (Tetany). These two findings occurred in the background of an unknown dog bite which helps indicate a Tetanus infection (lockjaw).
Tetanus (lockjaw) is an acute disease caused by neurotoxins (tetanospasmin) from the bacterium Clostridium tetani. C. tetani enters the body through broken skin (e.g., deep puncture wounds).
Rabies is a neurotropic virus contracted from the bite of an infected animal. The virus enters the patient's skin from the saliva of the animal and migrates along the peripheral nerves to the central nervous system (CNS). An incubation period of 4–12 weeks typically precedes the clinical appearance of the disease, which manifests with a prodrome of nonspecific flu-like symptoms, followed by acute rabies encephalitis. Clinical findings include fever, hydrophobia, hypersalivation, and stupor alternating with mania.
Ischemic stroke: cerebral infarction due to insufficient cerebral blood flow (hypoperfusion), which results in ischemia and neuronal injury. Commonly associated with Atherosclerosis (patient has a history of Myocardial Infarction).
Transient ischemic attack: temporary, focal cerebral ischemia; that results in neurologic deficits without acute infarction or permanent loss of function (previously defined as lasting < 24 hours).
Hemorrhagic stroke: cerebral infarction due to hemorrhage. Commonly associated with elevated blood pressure and a severe headache ("worst headache of my life").
Quinsy: Peritonsillar abscess which occurs due to Bacterial infection (mostly streptococcal).
Glomerulonephritis are a group of disorders where the damage to the glomerular filtration apparatus causes a leak of protein +/- blood into the urine, depending on the form. Patients may be asymptomatic or present with hematuria ( red cell casts), proteinuria, edema or hypertension. Acute glomerulonephritis has a sudden onset while the chronic form has a gradual onset. Note that these changes occurred after the infection two weeks ago.
Pyelonephritis refers to the bacterial infection of the renal pelvis. Symptoms include fever, oliguria, vomiting, pain.
Urolithiasis refers to the lodging of stone in the urinary tract.
Histologically, the stomach is made up of parietal and chief cells. The parietal cells secrete Hydrochloric acid responsible for the stomach’s acidity (intrinsic factor) which helps in digestion and Vitamin B12 absorption. Gastric chief cells secrete Pepsinogen which is converted into pepsin and helps in protein digestion. Notice that the RBC level is low and the test result revealed parietal cell antibodies which helps suggest that this patient has Vitamin B12 anemia (pernicious anemia). As earlier stated, Gastric acidity (intrinsic factor) is necessary for the absorption of vitamin B12, its absence due to parietal cells destruction by antibodies will lead to vitamin B12 deficiency.
Boric acid Medical uses include;
antiseptic in burns, cuts and dressing.
Vaginal douche in bacterial vaginosis and candidiasis.
Prevention of athlete’s foot, otitis externa.
Obzidan is also known as Propranolol, inderal is a drug indicated for the treatment of high blood pressure, a number of types of irregular heart rate, thyrotoxicosis, capillary hemangiomas, performance anxiety, and essential tremors. It is classified as a beta blocker (non- selective); weak indirect α1-adrenoceptor agonist in addition to potent β-adrenoceptor antagonist.
Reserpine is an adrenergic blocking agent used to treat mild to moderate hypertension via the disruption of norepinephrine vesicular storage. The antihypertensive actions of Reserpine are a result of its ability to deplete catecholamines from peripheral sympathetic nerve endings. These substances are normally involved in controlling heart rate, force of cardiac contraction and peripheral resistance.
Cavernous sinus thrombosis is usually a late complication of an infection of the central face or paranasal sinuses. In cavernous sinus thrombosis, a blood clot blocks a vein that runs through a hollow space underneath the brain and behind the eye sockets ( the cavernous sinus). Notice that this patient has a carbuncle located on the side of the face; this infection is most likely to spread via the sinuses. Cavernous sinus thrombosis can be a complication of this infectious process.
Notice that this patient has a history of pulmonary tuberculosis. Renal tuberculosis occurs due to hematogenous spread of Mycobacterium Tuberculosis to the kidneys. It is the second most frequent kind of extrapulmonary tuberculosis. Key findings include increased frequency, dysuria ( painful urination), back pain, hematuria ( blood in urine) etc.
Urolithiasis refers to stones in the urinary tract. Dysuria, hematuria are also found in this condition.
Glomerulonephritis are a group of disorders where the damage to the glomerular filtration apparatus causes a leak of protein +/- blood into the urine, depending on the form. Patients may be asymptomatic or present with hematuria ( red cell casts), proteinuria, edema or hypertension. The chronic form has a gradual onset.
In Chronic cystitis ( inflammation of the bladder), there will be a burning sensation in the pelvic region with the frequent urge to urinate.
From the complaints of this patient ( dyspnea on exertion, cough accompanied by mucus production etc) we understand that this patient has been having exacerbations of COPD ( chronic obstructive pulmonary disease) - Chronic bronchitis. Berodual ( Ipratropium Bromide) is a Short acting Muscarinic agent ( anticholinergic drug) with a bronchodilatory effect and is one of the drugs indicated for the management of COPDs. Note that for The management of acute exacerbation of COPDs, an Inhaled Corticosteroid plus a Long acting Beta 2 Agonist should be administered.
Bacillus anthracis is an aerobic, non-motile, spore forming, large non-hemolytic Gram-positive rod that grows well on blood agar. The clinical manifestations of human anthrax - Cutaneous and Inhalation.
Cutaneous anthrax, the most common form of naturally occurring disease, begins as a small, painless, pruritic papule that within 2 days enlarges, develops vesicles, and ulcerates to form an eschar. Inhalational anthrax follows inhalation of infectious doses of anthrax spores.
When anthrax spores get into the skin, usually through a cut or scrape, a person can develop cutaneous anthrax. Human cases may follow contact with contaminated carcasses (dead calf) or animal products. This can happen when a person handles infected animals or contaminated animal products like wool, hides, or hair. Cutaneous anthrax is most common on the head, neck, forearms, and hands. It affects the skin and tissue around the site of infection.
Bubonic plague is caused by bacteria called Yersinia pestis. It’s usually spread by fleas. These bugs pick up the germs when they bite infected animals like rats, mice, or squirrels.
Toxicodermatosis is a disease of the skin caused by a poison or by an allergen. The causative agents may be such chemical substances as antibiotics, sulfanilamides, and bromine, iodine, arsenic, and mercury compounds, or such food products as berries, cheese, or fish. As described in this scenario, the rash appeared after visiting a restaurant. Toxicoderma can also occur as a metabolic disorder or an occupational disease.
The causative agent enters the body through the respiratory organs or the digestive tract, during injections, or by direct contact with the skin. The primary manifestation of toxicoderma is a rash, which is generally symmetrical; it can take the form of inflamed or hemorrhagic maculae, papule, or vesicles (blisters). In severe cases, widespread areas of the skin are affected (erythroderma) and the patient manifests fever, cardiovascular disorders, or symptoms of anaphylactic shock.
With the removal of the allergen the symptoms of toxicoderma rapidly disappear, although relapses (usually severe) may occur with subsequent repeated exposure to the causative agent. Treatment consists in avoiding contact with the suspected allergen or toxic agent, as well as in the use of desensitizing agents and of expectant treatment.
Atopic dermatitis is a chronic condition that requires symptom management. It’s characterized by an itchy, red rash that usually appears at joints in your body, such as knees or elbows, and even around the neck. This condition occurs in flare-ups or bouts, meaning that it gets worse and improves in irregular cycles.
Many doctors use the terms “atopic dermatitis” and “eczema” interchangeably. They are both generic terms for “inflammation of the skin.” Eczema usually starts in early infancy, but also affects a substantial number of adults. It is commonly associated with elevated levels of immunoglobulin E (IgE) and a series of allergic diseases—including food allergy, asthma, and allergic rhinitis.
Contact Dermatitis occurs when your skin has a reaction to something it’s come in contact with. This can include bleach, soap, poison ivy, certain metals, or other irritants. The rash is typically red and may itch or burn.
A positive Lasegue’s sign - Straight leg raise test refers to the sensation of pain by applying pressure to the piriformis muscle and its tendons , particularly when the hip is flexed at the angle of 90° and the knee extended. A positive straight leg raise test usually indicates S1 or L5 root irritation. To support this diagnosis, a radiography of the spinal column should be carried out in the first place.
The question is asking for the best antiarrhythmic medication or tactic to be employed in managing this patient’s atrial fibrillation.
Cordarone is in the same class as Amiodarone, an antiarrhythmic drug Class III - Potassium channel blocker. Other medications in this class include Ibutilide, Sotalol, Dofetilide. Indications - Atrial fibrillation, atrial flutter, ventricular tachycardia.
Lidocaine is an antiarrhythmic drug Class IB - Sodium channel blocker used to treat Acute ventricular arrhythmias especially Post Myocardial Infarction.
Defibrillation is commonly used in cases of ventricular fibrillation or pulseless ventricular tachycardia.
Heparin is an anticoagulant. It is not an antiarrhythmic medication.
Acute Pancreatitis refers to the inflammation of the pancreas usually caused by alcohol consumption or biliary tract disorders. Acute pancreatitis usually presents with epigastric pain radiating to the back, nausea and vomiting, and epigastric tenderness on palpation. These signs are accompanied by the release of proteolytic enzymes from the pancreas that cause autodigestion. Notice that the patient’s diastase level is high, diastase refers to groups of enzymes that catalyze the breakdown of starch to maltose; these enzymes include α,β and γ amylase (especially α). The diastase level is useful in the diagnosing of diseases such as pancreatitis, jaundice, gall stones etc.
In Acute myocardial infarction Biomarkers such as Troponin, Creatinine phosphokinase (MB isoform) and myoglobins will be elevated on biochemical analysis.
This Patient presents with Acute Kidney Failure which is defined as a significant reduction in renal function occurring over hours or days clinically manifesting as an abrupt and sustained rise in serum urea and creatinine. It might be asymptomatic but oliguria is common. Life threatening consequences include volume overload ( presents as edema), increased potassium levels and metabolic acidosis. Note that plasma potassium levels > 7 mmol/l is an indication for Dialysis. Hemodialysis is a procedure used for removal of waste materials from the blood through filtration.
Lung abscess is a type of liquefactive necrosis of the lung tissue and formation of cavities (more than 2 cm) containing necrotic debris or fluid caused by microbial infection. It can also be caused by aspiration, which may occur during altered consciousness and it usually causes a pus-filled cavity.
Recall that An abscess is a cavity filled with Purulent content found within body tissue. This patient presents with an acute abscess of the left lung and can be easily identified on X-ray fluid as a cavity with air-fluid level.
One major complication of an abscess is the rupture and release of its content into surrounding tissues. This is a serious medical concern. Potential complications following rupture of an abscess could lead to Empyema - this is a large collection of infected fluid around the lung that occurs where the abscess is. As seen in this patient with air and horizontal fluid level in the pleural cavity.
The patient in question already has diffuse toxic goiter with clinical manifestation of hyperthyroidism. Thyroid storm, also referred to as thyrotoxic crisis, is an acute, life-threatening, hypermetabolic state induced by excessive release of thyroid hormones in individuals with thyrotoxicosis. During a thyroid storm, an individual’s heart rate, blood pressure, and body temperature can soar to dangerously high levels. Without prompt, aggressive treatment, thyroid storm is often fatal. Thyroid storm may be precipitated by the stress of surgery, anesthesia, or thyroid manipulation and may be prevented by pretreatment with antithyroid drugs.
A 26 year old male patient that presented with arthritis, prostatitis and conjunctivitis raised strong suspicion for a sexually transmitted infection with Chlamydia or Reactive Arthritis in which Chlamydia is also a culprit.
Chlamydia is a common sexually transmitted infection caused by bacteria. In men, it can manifest with urethritis which can spread to the prostate causing Prostatitis; conjunctivitis; Arthritis and commonly cause pelvic inflammatory disease (PID) in women. Chlamydia is an obligate intracellular organism and often treated with macrolides (Azithromycin) or Tetracyclines. Drugs’ ability to accumulate intracellularly makes them very effective against Chlamydia.
Penicillin is the drug of choice in the case of Syphilis; Cephalosporin (Ceftriaxone) in the case of Gonorrhea.
People with bladder cancer may experience the following symptoms or signs: Blood or blood clots in the urine (Hematuria) which is usually painless; Pain or burning sensation during urination; Frequent urination; Feeling the need to urinate many times throughout the night (Nocturia); Feeling the need to urinate, but not being able to pass urine etc.
Most often, bladder cancer is diagnosed after a person tells his or her doctor about blood in the urine, also called hematuria. "Gross hematuria" means that enough blood is present in the urine that the patient can see it. It is also possible that there are small amounts of blood in the urine that cannot be seen. This is called "microscopic hematuria," and it can only be found with a urine test.
Renal tumor will present with hematuria, flank pain and palpable mass which is absent in this patient. Urolithiasis will also present with colicky flank pain (lumboabdominal pain), hematuria, vomiting, which are also not present in this patient. Hematuria is not usually associated with Acute or Chronic Cystitis, suprapubic pain is more common with these conditions.
The term inflammatory bowel disease describes a group of disorders in which the intestines become inflamed. Two major types of inflammatory bowel disease are Ulcerative colitis and Crohn’s disease. Ulcerative colitis is limited to the colon or large intestine. Crohn’s disease, on the other hand, can involve any part of the gastrointestinal tract from the mouth to the anus.
The patient in question suffers from Ulcerative colitis. Common complications include; Toxic megacolon (toxic dilatation of the colon), or fulminant colitis. If Ulcerative colitis attack is severe, the colon might burst, or infection could spread through your body. Your intestines stop moving waste, and your belly swells. However, if a toxic megacolon is not urgently attended to, it could further lead to perforation.
Fistulas, abscess, and strictures are commonly associated with Crohn’s disease.
This patient’s illness of an acute infection that lasted for 3 days with fever, hepatomegaly, jaundice and resolved on its own is consistent with Acute Hepatitis. Hepatitis B, C and D commonly manifest as chronic illnesses, while Hepatitis E is commonly associated with pregnant women. Hepatitis A on the other hand is transmitted fecal-orally and can produce an acute hepatitis infection in which the patient can recover completely with or without treatment.
Hepatitis A is a highly contagious liver infection caused by the hepatitis A virus. You're most likely to get hepatitis A from contaminated food or water or from close contact with a person or object that's infected. Mild cases of hepatitis A don't require treatment. Most people who are infected recover completely with no permanent liver damage.
IgM indicates an Acute Infectious process (IgM Anti-HAV - IgM Antibody to hepatitis A virus). IgG indicates a Chronic Infectious Process and it can be seen in immunized patients.
Of all the options listed, only IgM Anti-HAV will verify the diagnosis. Complete Blood Count will show increased Lymphocytes (shows an active viral infection) but will not verify which particular virus. Other options will tell us there is a pathology somewhere in the liver but none will verify the particular virus.
The patient abused Vodka the night before he presented to the hospital with dizziness, profuse hematemesis (bloody vomit). Heavy alcohol ingestion is considered to be one of the most important predisposing factors as about 50% to 70% of the patients diagnosed with Mallory-Weiss syndrome have a history of the same.
Mallory-Weiss syndrome (MWS) is one of the common causes of acute upper gastrointestinal (GI) bleeding, characterized by the presence of longitudinal superficial mucosal lacerations (Mallory-Weiss tears). These tears occur primarily at the gastroesophageal junction; they may extend proximally to involve the lower or even mid esophagus and at times extend distally to involve the proximal portion of the stomach.
It is a lower esophageal lacerations (not ulcerations) happening to patients with repetitive forceful retching and vomiting following excessive alcohol intake.
The conjunctiva is a thin, translucent, relatively elastic tissue layer with both bulbar and palpebral portions. The bulbar portion of the conjunctiva lines the outer aspect of the globe, while the palpebral portion covers the inside of the eyelids.
Conjunctivitis refers to any inflammatory condition of the membrane that lines the eyelids and covers the exposed surface of the sclera. It is the most common cause of “red eye.”
Chronic conjunctivitis is most commonly caused by Staphylococcus species, although other bacteria are occasionally involved. This type of conjunctivitis often develops in association with blepharitis - bacterial colonization of the eyelid margins (palpebral conjunctiva is hyperemic and quaggy). The symptoms of chronic conjunctivitis include itching, burning, a foreign-body sensation and morning eyelash crusting, flaky debris, erythema and warmth along the lid margins, as well as eyelash loss and bulbar conjunctival injection (red eye).
Acute bacterial conjunctivitis typically presents with burning, irritation, tearing and, usually, a mucopurulent or purulent discharge and usually self-limited.
Paradoxical Ischuria is also known as urinary retention which refers to the inability to completely empty the bladder. It results from either a blockage that partially or fully prevents the flow of urine, or your bladder not being able to maintain a strong enough force to expel all the urine. Note that Urinary Incontinence and Urinary retention are completely opposite terms. Urinary Incontinence refers to the inability to hold urine and occurs when the control of the urinary sphincter is lost or weakened.
Notice that there is a suprapubic spherical bulging with percussion dullness - this is indicative of a full bladder which implies that this possess is unable to empty the bladder ( paradoxical ischuria/ urinary retention).
This patient clearly shows signs of auditory hallucination which is very often seen in patients with Schizophrenia. Auditory hallucinations, or hearing voices, is a common symptom in people living with Schizophrenia. These voices can call your name, argue with you, threaten you, come from inside your head or via outside sources, and can begin suddenly and grow stronger over time.
Hallucinations: perceptions in the absence of external stimuli e.g. seeing a light that is not actually present; hearing or talking to someone when no one is actually there. Types: Auditory (common in Psychiatry illnesses like Schizophrenia); Visual (common with delirium, drug intoxication); Olfactory; Tactile (e.g. ‘Cocaine crawlies’) etc.
Normal Rbc level in the blood ranges from about Male: 4.3 − 5.9 · 1012/L Female: 3.5 − 5.5 · 1012/L and hemoglobin level: Male: 135-175 g/L; Female: 120-160 g/L. A reduction in these values in the blood test indicates Anemia. Red blood cells are produced in the bone marrow of large bones and a bone marrow biopsy is needed for diagnosis. Platelets and White Blood Cells are also markedly decreased in this case. We are actually looking at a case of Pancytopenia.
Pancytopenia occurs when a person has a decrease in all three blood cell types. This happens when something is wrong with the bone marrow, where blood cells are formed. Pancytopenia has many possible causes: Diseases such as cancer, lupus or bone marrow disorders. Sternal puncture which is a type of bone marrow biopsy is indicated to verify the diagnosis.
Infection with H pylori is associated with the development of peptic ulcer disease, gastric cancer, and mucosa-associated lymphoid tissue lymphoma. Treatment Regimens for Eradication of H. pylori are omeprazole, amoxicillin, and clarithromycin (OAC) for 10 days; bismuth subsalicylate, metronidazole, and tetracycline (BMT) for 14 days; and lansoprazole, amoxicillin, and clarithromycin (LAC), which has been approved for either 10 days or 14 days of treatment.
Proton Pump Inhibitors (PPI) are the first line antisecretory agents used in treating H. Pylori associated Peptic Ulcer Disease. Examples of PPI’s include: Omeprazole; Lansoprazole; Esomeprazole; Pantoprazole. They irreversibly inhibit H+/K+ ATPase in stomach parietal cells.
Famotidine, Cimetidine are examples of H2-Histamine receptor blockers. This class of antisecretory agents are older than Proton Pump Inhibitors and no longer first line antisecretory agents due to their adverse effect profile such as multiple drug interactions, antiandrogenic effects etc.
An angina refers to chest pain due to an ischemic myocardium secondary to coronary artery narrowing or spasms. Canadian Cardiovascular Society grading of angina pectoris is a classification used to grade the severity of Angina.
Class 0: Asymptomatic Angina- Mild myocardial ischemia with no symptoms.
Class I: Angina only with strenuous exertion- Presence of angina during strenuous, rapid, or prolonged ordinary activity (walking or climbing the stairs).
Class II:Angina with moderate exertion- Slight limitation of ordinary activities when they are performed rapidly, after meals, in cold, in wind, under emotional stress, during the first few hours after waking up, but also walking uphill, climbing more than one flight of ordinary stairs at a normal pace and in normal conditions.
Class III: Angina with mild exertion- Having difficulties walking one or two blocks or climbing one flight of stairs at normal pace and conditions e.g walking short distances (20 - 100m)
Class IV: Angina at rest- No exertion needed to trigger angina.
The patient in perspective experiences anginal symptoms after he walks about 700 - 800m (a short distance and normal activity).
The New York Heart Association (NYHA) also classifies the extent of heart failure. It classifies patients in one of the four categories based on their limitations during physical activity.
CLASS I: No symptoms and no limitation in ordinary physical activity
CLASS II: Mild symptoms (mild shortness of breath and/or angina) and slight limitation during ordinary activity.
CLASS III: Marked limitation in activity due to symptoms, even during less than ordinary activity e.g. walking short distances (20 - 100m). Comfortable only at rest.
CLASS IV: Severe limitations. Experiences symptoms even while at rest.
From anamnesis, we understand that the patient has just returned from Tajikistan (Asia) , this should prompt the idea of a malarial infection. Malaria is caused by a plasmodium infection (P.vivax, P.falciparum, P.malariae, P.ovale. In its life cycle, various stages are involved.
Osteosarcoma is a type of cancer that produces immature bone. It is the most common type of cancer that arises in bones, and it is usually found at the end of long bones, often around the knee. Presents as a painful enlarging mass or pathologic fractures. A codman Triangle ( from elevation of the periosteum) or sunburst pattern are classical findings on radiography. Note that in the blood immature cells were found. The absence of signs of inflammation rules out the option of Chronic osteomyelitis ( which is an infection of the bone tissue) .
Multiple myeloma is also known as B-cell myeloma. It is a form of cancer that affects the plasma cells. Bence Jones proteins are a key finding in this pathology.
Marble bone disease is also called Osteopetrosis or Albers-Schonberg disease. It is a rare inherited disorder in which the bone hardens and becomes denser ( stone bone). It is the opposite of osteoporosis and osteomalacia.
Esophageal cancer refers to a malignant tumor of the esophagus. The esophagus is the tube that connects the throat with the stomach. The two main subtypes of esophageal cancer are:
Squamous cell carcinoma: This arises from the cells lining the upper part of the esophagus.
Adenocarcinoma of the esophagus: This occurs due to changes in the glandular cells that exist at the junction of the esophagus and the stomach.
The junction between the stomach and esophagus (Gastroesophageal junction) is already narrower than other parts of the esophagus. So, having a cancer develop at this junction or close to it just exacerbates the condition and prevents free passage of food starting with solids.
People often experience no symptoms during the initial stages of this cancer. The majority of esophageal cancer diagnoses occur when the cancer has advanced.
When symptoms are present, they may include and usually the first noticeable symptom: Dysphagia (difficulty in swallowing). As the tumor narrows the passage in the esophagus, pushing food through becomes harder. And eventually, if the growth goes on unchecked, it begins to become narrower and affects semi-solids and then at the terminal stage, liquids.
The first point to take note of here is that the patient had his right maxillary premolar filled a month ago.
Sinusitis is the inflammation of one or multiple sinuses. Your sinuses are hollow air-filled cavities (like pouches) behind your forehead, cheeks and eyes. Odontogenic sinusitis is any inflammation of a dental origin and of your sinuses. It’s almost always one of the maxillary sinuses that are affected. These can be found to the right and left of your nose, behind the cheeks.
This condition occurs when a dental infection caused by lack of oral hygiene or dental surgery, such as tooth implants, a tooth removal or a sinus lift, reaches the maxillary sinus. Your teeth project up towards the maxillary sinus, and sometimes directly into it. There is a membrane called the Schneiderian membrane that protects your sinuses from teeth and teeth infections, but if surgery or a tooth’s root disrupts the membrane, the infection can spread.
Odontogenic sinusitis accounts for the majority of cases of chronic maxillary sinusitis. It is the most common cause of unilateral maxillary sinusitis
Lobectomy has been generally recommended as an optimal surgical approach for symptomatic unilateral goiter, toxic adenoma, and low-risk differentiated thyroid cancer. Although patients are expected to maintain normal thyroid function after lobectomy or subtotal resection since not all the thyroid tissue was resected, some patients develop hypothyroidism that requires thyroid-hormone replacement. Routine levothyroxine (L-Thyroxine) supplementation is commonly prescribed for prophylaxis of postoperative hypothyroidism.
Merkazolil and Iodomarin can be used in case of Hyperthyroidism. They are anti-thyroid medications. Lithium is commonly used in Psychiatry cases for Bipolar conditions but it is commonly associated with Hypothyroidism and will not be useful in this case.
The glycated hemoglobin (HbA1c) test is an important blood test that determines how well you are managing your diabetes. The hemoglobin A1c test tells you your average level of blood sugar over the past 2 to 3 months.
Considering the critical condition of this patient, active core warming by using warmed intravenous fluids which gets into the system immediately and will bring the most desired result at the shortest time possible is by far the best treatment recommendation.
Extension of a tonsil infection can take place in the surrounding tissue and is referred to as a Peritonsillar abscess or quinsy. The 26 year old man had previously had quinsy but didn’t follow medical advice. This complication of tonsillitis is usually caused by a B-hemolytic streptococcal infection and are characterised by an extremely sore throat and high fever ( as seen in the patient) .
A peritonsillar abscess forms in the tissues of the throat next to one of the tonsils. An abscess is a collection of pus that forms near an area of infected skin or other soft tissue. The abscess can cause pain, swelling, and, if severe, blockage of the throat. If the throat is blocked, swallowing, speaking, and even breathing become difficult.
The key sign that distinguishes quinsy/peritonsillar abscess from ordinary tonsillitis is the presentation of trismus. Trismus is usually absent in any form of tonsillitis but would be seen in a Peritonsillar abscess.
Benign prostatic Hyperplasia is a non carcinogenic pathology that occurs mostly in men above 40. It presents with symptoms similar to Prostate cancer. These include frequency of urination, hesitancy, dribbling, and frequent nighttime urination. To differentiate between these two pathologies, an objective examination is carried out ( a digital rectal examination ). In this case, the prostate is dense, enlarged, elastic and well defined with no nodes - these findings support the initial diagnosis of BPH because on digital rectal examination, prostatic carcinoma will not be well defined and will present with nodes. To further prove this diagnosis, the Prostate specific antigen is measured ( normal <4). A marginal increase is going to support the diagnosis of BPH while PSA of 10 and above will indicate prostate cancer.
An Addisonian crisis most often occurs in a patient with known adrenal insufficiency (this patient has a history of Addison’s disease), either primary or secondary. Primary adrenal insufficiency (Addison Disease) is characterized by low cortisol and high ACTH from the destruction of the adrenal glands. Chronic, stable primary adrenal insufficiency is called Addison's disease, which is a chronic condition controlled with long-term glucocorticoid therapy.
Addisonian crisis, also known as adrenal crisis or acute adrenal insufficiency is an endocrinologic emergency commonly seen in patients with known adrenal insufficiency. It is characterized as an acute change in physiologic status, quickly progression from nonspecific symptoms of fatigue, weakness, nausea, vomiting, abdominal pain, back pain, diarrhea, dizziness, hypotension, syncope, eventually to obtundation, metabolic encephalopathy, and shock.
Most cases are patients with known adrenal insufficiency who experience an acute stress event (patient had flu), who do not adjust their usual dose of glucocorticoid therapy and their body's cortisol stores are quickly depleted leading to an Addisonian crisis as these patients cannot produce their own cortisol. Roughly half of the patients have undiagnosed Addison's disease and present to the emergency room in acute crisis and shock after an acute stress event.
One of the most common complications occurring post-infarction is a ventricular aneurysm. Almost 85% to 90% of the ventricular aneurysms occur in the setting of acute anterior wall myocardial infarction. Left ventricular aneurysm is defined as a localized area of myocardium with abnormal outward bulging and deformation during systole and diastole. The natural course leading to the formation of a ventricular aneurysm involves a full-thickness infarct that has been replaced by fibrous tissue. This inert portion cannot take part in the contraction and herniates outward during systole.
Dermatophyte infections, also known as tinea, are the most common fungal infections of the skin, hair, and nails.The term "Dermatophyte" refers to fungal species that infect keratinized tissue, and includes members of the Trichophyton, Microsporum, and Epidermophyton genera.
Trichophyton rubrum is a dermatophytic fungus. It colonizes the upper layers of dead skin, and is the most common cause of athlete's foot, fungal infection of nail, jock itch, and ringworm worldwide. T. rubrum colony shows Partial yellow-green fluorescence under wood-lamp.
T. rubrum is now the most common cause of invasive fungal nail disease (called onychomycosis or tinea unguium). Nail invasion by T. rubrum tends to be restricted to the underside of the nail plate and is characterized by the formation of white plaques on the lunula that can spread to the entire nail. The nail often thickens and becomes brittle, turns brown or black.
The question clearly states that inoculation onto Sabouraud medium resulted in growth of T. rubrum colony which makes Rubromycosis the correct answer and rules out Epidermophytosis and Psoriasis (patient must have psoriasis first before a diagnosis of Psoriasis of the nails can be made).
Hydradenitis refers to small painful lumps that form under the skin usually in areas of friction such as: axilla, groin, buttocks and breast.
Carbuncle: clusters of boil; an area of subcutaneous necrosis which discharges itself unto the surface through multiple sinuses.
Furuncle ( boil) - forms under the hair follicle and associated glands which contains pus.
Partial Thromboplastin Time (PTT): <28seconds (normal)
PTT in this patient is 89seconds.
Defect in the Intrinsic coagulation pathway results in an Increased Partial Thromboplastin Time (PTT).
Intrinsic pathway coagulation defect:
Hemophilia A: deficiency of Factor VIII
Hemophilia B: deficiency of Factor IX
Hemophilia C: deficiency of Factor XI
Hemophilia is usually an inherited bleeding disorder in which the blood doesn't clot properly. This can lead to spontaneous bleeding as well as bleeding following injuries or surgery. Blood contains many proteins called clotting factors that can help to stop bleeding. People with hemophilia have low levels of any of factor VIII (8); factor IX (9) or factor XI (11).
Hemophilia commonly presents as hemarthrosis (bleeding into joints e.g. knee); easy bruising; bleeding after trauma or surgery (e.g. dental procedures).
Patent ductus arteriosus is a congenital heart anomaly in which the ductus arteriosus fails to close at birth. PDA is normal in utero and normally closes only after birth. Due to the failure of the ductus arteriosus ( a connection between the aorta and pulmonary artery), oxygenated blood flows from the aorta into the pulmonary artery then back to the lungs for more oxygenation. Key signs include: dyspnea, tachycardia, cyanosis of the lower extremities etc. On objective examination, we observe increased systolic pressure, left subclavicular thrill, a continuous rasping systo diastolic murmur in the 2nd intercostal space on the left; this murmur can also be termed like “a machine gun” or “rolling thunder”. Echocardiogram and normal chest x-ray are used in the diagnosis. One major finding on chest x-ray is the cardiac Silhouette (loss of normal borders between thoracic structures).
From anamnesis, this patient has a history of Gastroesophageal reflux disease; a condition that occurs as a result of weakening of the lower esophageal sphincter. Due to the weakening of the LES, gastric contents flow back into the esophagus leading to symptoms such as heartburns, retrosternal pain, constipation etc. The result from Esophagoduodenoscopy shows the presence of ulcers, stricture and edema at the lower end of the esophagus. For more accurate diagnosis, during the EGD, a biopsy of the esophageal mucosa should be obtained. This biopsy is used to check for an abnormal growth, pre existing infection etc.
The absence of peripheral edema in this patient helps rule out the use of diuretics - this group of drugs will be in the first line of action if the patient presents with any forms of edema. The groups of Drugs indicated for the secondary prevention of heart failure include: Angiotensin Converting enzyme inhibitor ( ACE inhibitors) or Angiotensin Receptor blockers ( ARBs), Beta blockers, Calcium channel blockers, Diuretics etc. Amongst these, a combination between ACE inhibitors and Beta blockers has proved to be more effective than monotherapy.
The results from the ECG ( ST elevation in II, III and AVF) indicates an acute myocardial infarction of the inferior wall. Myocardial infarction is the leading cause of cardiogenic shock. Others include; arrhythmias, heart failure, cardiac trauma, mitral valve regurgitation etc. Cardiogenic shock is a medical emergency in which the heart is unable to pump adequate blood to vital organs.
Anemia is a condition characterised by too ew RBCs . In iron deficiency anemia, we observe the presence of low hemoglobin levels coupled with a low color index; recall that iron is responsible for the characteristic red color in Rbc and a deficiency in Iron content in blood will lead to a decreased color index. In this patient, together with the RBC level, the color index and hemoglobin levels are also low ( norm Color index 0.85- 1.05, Hemoglobin, blood Male: 135-175 g/L Female: 120-160 g/L); Characteristics of individuals with iron deficiency anemia include; brittle hair and nails, pale skin and mucous membrane etc.
B12 deficiency will lead to the presence of megaloblasts in blood smear with the patient experiencing some neurological disturbances.
Anatomically, the carotid sinus is located at the proximal end of the internal carotid artery just above the bifurcation of the common carotid artery into the internal and external carotid artery. The carotid sinus houses baroreceptors (stretch receptors); The carotid sinus baroreceptor functions as a sensor responding to the mechanical stretch that occurs to the carotid artery as the arterial blood pressure increases. Notice that the above stated changes occurred on the background of an ultrasound study of the carotid and vertebral bodies.
Carotid sinus syncope (hypersensitivity) refers to an exaggerated response to carotid sinus baroreceptor stimulation. It is characterised by a drop in blood pressure with or without accompanying bradycardia.
Orthostatic syncope refers to the loss of consciousness resulting from the postural decrease in blood pressure ( change in position).
Morganani Adams stokes attack refers to periodic loss of consciousness due to a significant loss of cardiac output.
Absence of focal neurological signs rules out the options of acute cerebrovascular accident.
A positive pasternestky’s sign indicates kidney related pathology ruling out the option of Acute appendicitis, cholecystitis and pancreatitis. Urolithiasis and pyelonephritis ( infection of the kidney tubules mostly by bacteria) have many symptoms in common (eg, hematuria, flank pain, shaking chills, anorexia). Urolithiasis ( stones in the urinary tract) is usually not associated with fever, except in patients with concomitant pyelonephritis. The best way to differentiate these diseases is by conducting a renal ultrasonography.
Note that Tuberculosis is the most common cause of Addisson’s disease ( primary adrenal insufficiency). Adrenal insufficiency is the decreased production of adrenocortical hormones (glucocorticoids, mineralocorticoids, and adrenal androgens) and can be primary, secondary, or tertiary. Primary adrenal insufficiency (Addison disease) is caused by a disorder of the adrenal glands. Patients with long-standing adrenal insufficiency can present with postural hypotension, nausea, vomiting, weight loss, anorexia, lethargy, depression, and/or chronic hyponatremia. Patients can also present with loss of libido as a result of hypoandrogenism. Patients with primary adrenal insufficiency also tend to develop hyperpigmentation of the skin, mild hyperkalemia, and metabolic acidosis. The glycemic level of 3.0 mmol/l rules out the option of diabetes mellitus.
Recall that an abscess refers to a pus filled cavity found within tissues. The result from the chest radiography confirms a rounded shadow ( a cavity) in the lower lobe of the right lung with a horizontal fluid level ( purulent content). This patient presents with a primary abscess which occurs on the background of a pneumonia infection.
In Pleuropneumonia, the inflammation of the lung is accompanied by the inflammation of the pleura ( pneumonia plus Pleurisy).
In pulmonary empyema and pleural effusion, purulent contents build up within the pleural space and also occurs as a complication of bacterial pneumonia.
Atelectasis is a loss of lung volume that may be caused by a variety of ventilation disorders, for instance, bronchial injury or an obstructive mass such as a tumor.
Sour regurgitation, cough, heartburns after meals are key findings in Gastroesophageal reflux disease. In this disorder, there occurs a backflow of acidic content of the stomach into the lower end of the esophagus leading to inflammation and formation of erosions. This disorder occurs due to the failure of the lower esophageal sphincter to function properly; its inability to close properly allows for the backflow of gastric content. A Fibroesophagogastroduedenoscopy is usually carried to confirm diagnosis- in this case we observe an endo esophagitis which helps confirm this diagnosis.
Immunophenotyping is an analysis of heterogeneous ( various) populations of cells for the purpose of identifying the presence and proportions of the various populations ( identifying how much of each cell type is present). This technique works on the basis of identifying different cell markers or antigens peculiar for each cell type.
This patient presents with low RBC, WBC and platelets coupled with an increased blast cell level; the result from the general blood analysis suggests a leukemia or a lymphoma. Immunophenotyping will help specify the diagnosis.
Cytogenetic study is used to analyze the structure of chromosome material and the study of diseases caused by structural and numerical abnormalities of chromosomes.
Notice that this patient has thrombophlebitis- a condition in which blood clots form and block an already inflamed vein(s). This condition can be superficial or deep ( deep vein thrombosis- as in this case). Pulmonary embolism is one of the various complications of DVT- this occurs when a clot or substance formed elsewhere travels and blocks an artery in the lungs. Sharp pain in the thorax and hemoptysis coupled with weakened respiration are clinical findings in this condition.
Notice that this patient has Progressing renal parenchyma arterial hypertension accompanied by edemas of the leg; she is already on a combined medication that includes Losartan ( Angiotensin receptor blocker) and Lercanidipine ( a calcium channel blocker). On the basis that this patient has suffered from glomerulonephritis, currently having a renal induced hypertension, presents with edema and does not have a diuretic prescribed as part of the complex treatment, the preferred drug of choice to intensify this treatment will be Torasemide ( a loop diuretic).
This patient is already on an Angiotensin receptor blocker, there is no need to use an ACE inhibitor ( Lisinopril); we need to try another class with a different mechanism of action.
Hippocratic nails refer to a condition in which there is proliferation of the distal part of the fingers, especially the nail bed. Velcro Type crackles refer to bilateral crepitation heard especially during slow inspiration but can be associated with expiratory crackles. These types of crackles are seen in fibrotic interstitial lung diseases.
Hand-schuller-christain disease is characterised by a triad of single or multiple punched out bone lesions on the skull, uni/bilateral exophthalmos and diabetes insipidus. Other findings in this disorder include; infantilism, dwarfism and polyuria.
Of the above listed diagnostic procedures, the Computed tomography will be most appropriate in determining the scope of the pathologic process. Note that on examination, enlarged cervical lymph nodes were found; a CT scan is the best procedure ( among the listed) in examining these lymph nodes. An ultrasound will be appropriate for diagnosis of pathologies relating to internal organs.
Notice that from examination, the mouth is dry, chalk dusted describing a case of oral candidiasis (thrush). This condition is caused by the growth of Candida spp. ( a fungus ) in the oral cavity. An etiotropic therapy is a form of treatment targeted at the causative agent ( in this case the fungus- candida). Of the listed drugs, Ketoconazole is the only antifungal drug; other possible choices include Nystatin, Itraconazole. Ribavirin is an antiviral drug used in hepatitis C, RSV infections etc. Streptomycin is indicated in Tuberculosis and notable for its ototoxic side effect.
Note that the key finding here are the numerous wet crackles heard from the lungs; these crackles are heard when there is excess fluid in the airways. Pulmonary edema is usually seen in heart related issues ( in this case post MI); in this condition air sacs in the lungs are filled with fluid making it difficult to breathe.
Cardiogenic shock can also be caused by Myocardial Infarction but its clinical features include; Tachycardia, Hypotension, Cold/clammy extremities, weak pulse, slow capillary refill etc.
The blood pressure of this patient is 120/100 mmHg which rules out the option of hypertensive crisis, a condition in which the blood pressure is equal or greater than 180/120mmHg.
Note that from the blood analysis, the key finding is the presence of Gumphrect shadow (Smudge cells). These cells are seen in Chronic lymphocytic leukemia (CLL).
Chronic Myeloid leukemia (CML) is defined by Philadelphia Chromosome ( a translocation between chromosome 9 and 22) coupled with a myeloid stem cell proliferation.
Writer’s cramp is a specific form of focal dystonia that affects the fingers, hand, or forearm. Focal dystonia of the hands is a neurological movement disorder.
Cortical agraphia is a neurological disorder in which an individual loses the ability to communicate either through writing or he/she forgets how to spell.
Notice that from ultrasound, this patient presents with a tumor of the adrenal gland. From the results of the blood and biochemical analysis, we see an elevated cortisol, aldosterone coupled with increase in sodium levels - this indicates that the tumor is present in the adrenal cortex ( ruling out the option of Pheochromocytoma which is a tumor of the adrenal medulla and is characterised by elevated catecholamines and blood pressure). This patient has an aldosteroma ( an aldosterone producing adenoma); recall that aldosterone is produced by the zona glomerulosa of the adrenal gland and is responsible for the resorption of sodium and water during formation of urine coupled with deposition of potassium.
A pericardial friction rub is highly specific for Acute pericarditis. Pericarditis is an inflammation of the pericardium. Acute pericarditis is most commonly caused by viral infection; however, a number of conditions can cause an inflammatory response in the pericardium. Acute inflammation typically manifests with fever, pleuritic chest pain, and a pericardial friction rub on auscultation. The diagnosis is established based on clinical findings, although diffuse ST segment elevations on ECG and imaging may support the diagnosis.
A manic episode is characterized by a sustained period of abnormally elevated or irritable mood, intense energy, racing thoughts, and other extreme and exaggerated behaviors. People can also experience psychosis, including hallucinations and delusions, which indicate a separation from reality. The symptoms of mania can last for a week or more and manic episodes may be spaced within periods of depression during which you may experience fatigue, sadness, and hopelessness.
An abscess is a painful pus filled cavity usually caused by a bacterial infection. Renal abscess are also referred to as Renal corticomedullary abscesses; the key finding here is that there is no difference between the cortical and medullary layers of the kidney on CT scan which proves that the cortex and medulla are uniformly affected; also, we see edema and increased density of perinephric fat which occurs due to the accumulation of fluid.
The groups of drugs mostly used in the management of hypertension include; ACE inhibitors, ARBs, calcium channel blockers , Beta blockers, diuretics etc. Recall that Beta-blockers are drugs that bind to beta-adrenoceptors and thereby block the binding of norepinephrine and epinephrine to these receptors. This inhibits normal sympathetic effects that act through these receptors. Beta receptors are not only found in the heart ( beta 2) but also in the lungs ( beta 1); blocking of these receptors will cause the heart to slow down but have increased force of contraction, in the lungs- Bronchoconstriction. Bronchoconstriction is very dangerous in a patient with asthma thus NON- SELECTIVE BETA BLOCKERS eg Atenolol are contraindicated.
Facial (nerve) palsy is a neurological condition in which function of the facial nerve (cranial nerve VII) is partially or completely lost. Key findings include; Sensory disturbances : Painful sensation around or behind the ear, Impairment of taste in the anterior tongue , Hyperacusis; dropping of the mouth, dry mouth, Bell\'s phenomenon: a physiologic, reflexive movement of the eye (upward and outward) that occurs when the eyelid is actively closed, Lagophthalmos: The patient cannot fully close the eyes (due to paralysis of the orbicularis oculi muscle). Decreased lacrimation.
In neuropathy of the trigeminal nerve ( trigeminal neuralgia), the individual will feel excruciating pain at the slightest pressure applied on the face e.g. while brushing the teeth, yawning etc.
In neuropathy of the oculomotor nerve, the individual will experience diplopia and strabismus.
This patient has been diagnosed with type 2 diabetes mellitus ( non-insulin dependent diabetes). The results from the current blood sugar level and glycated hemoglobin supports it ; Norm blood glucose 3.5-5.5 mmol/L; normal glycated hemoglobin -6 %. For the treatment of type 2 Diabetes, Metformin also known as Glucophage (a biguanide) is usually the first drug to be administered.
Recall that Ammonia is converted to urea ( via the ornithine/urea cycle). Urea is then excreted from the body through the urine. Notice that this patient has no urinary output, smell of ammonia from the mouth coupled with an increased urea level in the blood. Recall that ammonia and urea (at high blood concentration like in this case) can cross the blood brain barrier leading to encephalopathy and further loss of consciousness. N/B the blood glucose and osmolarity levels are also elevated but not enough to lead to their respective forms of coma.
Observe that the intraocular pressure is 48mmHg ( norm is 10-21 mmHg). Glaucoma is a medical condition characterised by optic disc atrophy coupled with cupping, usually with an elevated intraocular pressure and progressive peripheral visual field loss if untreated.
Iridocyclitis is an inflammation of the anterior uveal tract ( iris and ciliary body) ; symptoms include blurred vision, eyes pain, photosensitivity, red eye ( conjunctival injection) etc.
Urticaria (hives) is a vascular reaction of the skin marked by the transient appearance of smooth, slightly elevated papules or plaques (wheals) that are erythematous and that are often attended by severe pruritus. Individual lesions resolve without scarring in several hours. Most cases of urticaria are self-limited and of short duration; the eruption rarely lasts more than several days, but may be recurrent over weeks. Chronic urticaria is defined as urticaria with recurrent episodes lasting longer than 6 weeks. Mostly occurs as a reaction towards food, drugs, contact etc.
Urticaria pigmentosa is composed of persistent brown or red marks, made of collections of mast cells that swell and itch transiently when rubbed, similar to a hive.
In Somatoform Autonomic dysfunction, the symptoms are presented by the patient as if they were due to a physical disorder of a system or organ that is largely or completely under autonomic innervation and control, i.e. the cardiovascular, gastrointestinal, respiratory, and urogenital systems. Clinical and instrumental examination revealed no organic alterations in any system therefore indicating a somatoform autonomic dysfunction.
Organic brain syndrome is defined as a state of diffuse cerebral dysfunction associated with a disturbance in consciousness, cognition, mood, affect, and behavior in the absence of drugs, infection, or a metabolic cause.
Ventricular fibrillation (VF) and myocardial ischemia are inseparable. Ventricular fibrillation most commonly occurs during an acute myocardial infarction or shortly thereafter. When heart muscle does not get enough blood flow, it can become electrically unstable and cause dangerous heart rhythms.
Fibrillation waves of varying amplitude and shape.
No identifiable P waves, widened or prolonged QRS complexes (norm: 0.12sec), or T waves
Heart rate anywhere between 150 to 500 per minute
Furthermore, Atrioventricular dissociation occurs when P waves, representing atrial depolarization, are seen at different rates than the QRS complexes. This is present in only a small percentage of Ventricular fibrillation ECG tracings, but it is diagnostic of VF. Frequently, it is difficult to identify the P waves due to the fast rate of the QRS complex.
Notice that this patient presents with a type 1 diabetes ( insulin dependent). In the absence of insulin, the body tends to release more glucose from the liver and free fatty acids from adipose tissue; these free fatty acids are then broken down into ketone bodies (acetoacetate and β-hydroxybutyrate) through the process of beta oxidation. Accumulation of these ketone bodies in the blood leads to metabolic acidosis due to the fact that ketone bodies reduce the blood pH level. The breath of a person with Diabetic ketoacidosis is usually associated with a specific smell ‘Fruity’ or “acetone”.
A diabetic hyperosmolar coma is caused by severe dehydration and very high blood glucose levels (hyperglycaemia). The kidneys respond to high levels of blood glucose by doing their best to remove it, along with a great deal of water. The person experiencing diabetic hyperosmolarity will be very thirsty coupled with a high level of osmolarity level from biochemical analysis.
Lactic academic coma occurs as a result of a buildup of lactic acid in the blood.
A thyroid fine needle aspiration biopsy is a procedure that removes a small sample of tissue from your thyroid gland. Cells are removed through a small, hollow needle. The sample is sent to the lab for analysis. In some cases, hard nodules form inside the gland. Most times, the nodules are not dangerous. But in some cases they can be thyroid cancer. A thyroid fine needle aspiration biopsy can take a sample from the nodule to test for cancer.
Thyroid scan (thyroid scintigraphy) is a nuclear medicine examination used to evaluate thyroid tissue. Clinical indications include; functional status of a thyroid nodule, thyrotoxicosis: differential diagnosis and thyroid cancer. Note that an ultrasound procedure has already been carried out therefore, carrying out a thyroid scintigraphy will just be a repetitive test.
Note that 18 days prior, this patient had a case of tonsillitis; this raises the idea of a group A beta hemolytic streptococci infection. This infection is most likely to cause glomerulonephritis (post streptococcal glomerulonephritis). Poststreptococcal (or post-infectious) glomerulonephritis (PSGN) refers to acute glomerular inflammation that results from a preceding infection with nephritogenic strains of streptococci. Deposition of immune complexes containing the streptococcal antigen within the glomerular basement membrane results in complement activation and subsequent damage to the glomeruli. PSGN typically presents as a nephritic syndrome with hematuria, mild proteinuria, edema, and hypertension. Elevated antistreptolysin O titers (ASO), low complement levels, and elevated creatinine support the diagnosis.
People with dependent personality disorder may submit to the will of others in a misguided attempt to extract a promise of care and protection. They may think of themselves, or present themselves, as unable to cope with everyday life on their own. At the same time, they may fear that a show of confidence or competence will lead to rejection and abandonment. They demand advice and reassurance when making even minor decisions. They take no initiative and let others assume responsibility for their lives.
Anankastic personality disorder is also known as Obsessive compulsive disorder (OCD),a disorder characterized by preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency.
Carbuncle: red, swollen, painful clusters of boil that are connected to each other under the skin.
Furuncle: refers to a Boil, forms around the hair follicle and contains pus.
Hydradenitis: ‘acne inversa’ , inflamed and swollen lumps found in the axillary region ( armpit), under the breast, groin. These lumps most times break open forming a fistula or tunnels
The background information here is that - this young lady with Type I Diabetes Mellitus presents with a 3cm swelling on the anterior surface of the hip.
Abnormal reaction in subcutaneous fat to insulin is called lipodystrophy which can be either hypertrophic or atrophic. Lipodystrophy is an exclusive complication of lean children and young Type 1 diabetic, although rarely can be seen in Type 2 diabetic.
Insulin lipohypertrophy denotes a benign tumor like swelling of fatty tissue at the injection site secondary to lipogenic effect of insulin, whereas lipoatrophy is considered an adverse immunological side effect of insulin therapy. Since the advent of recombinant human insulin and analogue, lipoatrophy, has virtually disappeared, whereas, lipohypertrophy still remains a serious local problem of insulin therapy.
With a swelling of 3cm, the best answer choice is development of hypertrophic lipodystrophy. Atrophic lipodystrophy will not have associated swelling, instead a depression should be observed.
Prevention, to avoid lipodystrophy, should take first place as there is little cure to it, and the best way is to educate the patient about rotating injection sites.
Notice that this patient presents with signs in relation to gallbladder or liver pathology (bile in general). In order to get the correct diagnosis, an Ultrasound of the liver, gall bladder and surrounding abdominal organs should be carried out.
The presence of antithyroid antibodies helps us understand that there is an autoimmune attack on the thyroids- This refers to Hashimoto’s thyroiditis; the most common cause of hypothyroidism. It is characterised by lymphocyte infiltration of the stroma of the thyroid gland leading to its destruction and signs of hypothyroidism. Other antibodies that can be found include those against thyroid peroxidase and TSH receptors. For its treatment, a replacement therapy is carried out using L-thyroxine.
Bronchiectasis is a condition in which damage to the airways causes them to widen and become flabby and scarred (X-ray findings - left lung root is deformed and dilated). The airways are tubes that carry air in and out of your lungs.
Bronchiectasis usually is the result of an infection or other condition that injures the walls of your airways or prevents the airways from clearing mucus.
The initial airway damage that leads to bronchiectasis often begins in childhood. However, signs and symptoms may not appear until months or even years after you start having repeated lung infections.
The most common signs and symptoms of bronchiectasis are:
A daily cough that occurs over months or years.
Daily production of large amounts of sputum (spit). Sputum, which you cough up and spit out, may contain mucus (a slimy substance), trapped particles, and pus.
Shortness of breath and wheezing (a whistling sound when you breathe).
Clubbing (the flesh under your fingernails and toenails gets thicker).
Over time, it may progress to more serious symptoms like coughing up blood (hemoptysis) or bloody mucus and feel very tired. Children may lose weight or not grow at a normal rate.
This patient is having an Anaphylactic reaction after being stung by a bee. Notice that he is having inflammation of the airway, making it difficult to breath. For emergency care , this patient should be administered Intravenous epinephrine and glucocorticoids to reduce inflammation and help improve breathing.
From the description; dirty gray coating with unpleasant sweet smell, resembling raspberry jelly with moderate criterion on palpation - this fits the description of a Gangrenous infection (gangrene); an infectious process caused by Clostridium Perfringens. Cl. Perfringens is a gram positive, rod shaped, spore forming anaerobic bacteria which is a major cause of food poisoning and gas gangrene.
Blue pus bacillus refers to pseudomonas aeruginosa.
Rubella ( accused by rubella virus) is an acute viral infection characterised by a short prodromal period, Exanthema ( rash) during three days and lymphadenopathy. The type of rash found is roseola and small macula-papula. Note that the rash elements do not merge ( non-merging spots) and are usually concentrated on the extensor surface of extremities, back, buttocks and outer surface of thigh.
Epstein-barr virus is one of the causative agents of Infectious mononucleosis- a disease characterised by prolonged fever, systemic lymphadenopathy,acute tonsillitis, acute adenoiditis, hepatosplenomegaly, along with typical blood changes such as lymphocytosis, monocytosis, presence of specific cells called atypical mononuclear cells or virocytes.
Mumps infection is a systemic disease characterised by hyperthermic syndrome,symmetrical or unilateral swelling of parotid glands, epididymo-orchitis etc.
Immune thrombocytopenic purpura (ITP) is a clinical syndrome in which a decreased number of circulating platelets (thrombocytopenia) present as a bleeding tendency, easy bruising (purpura), or extravasation of blood from capillaries into skin and mucous membranes (petechiae). Recall that the patient presents with dotted hemorrhages on the skin (petechiae) and on analysis, thrombocytopenia. Caused by the binding of an autoantibody (specifically IgG) to platelets leading to platelet destruction.
In Hemophilia, patients will present with bleeding from joints (hemathroses), easy bruising or a case of bleeding after surgery, dental procedure. Has three forms; Hemophilia A ( Factor VIII deficient), Hemophilia B ( factor IX deficient), C ( factor XI def.).
This patient presents with Classical signs of Reactive arthritis ( He can’t See , Pee or Bend The Knee) ie, purulent discharge from the eyes, burning sensation while urinating and pain in his leg joints. Reactive arthritis is an autoimmune condition that develops in response to an infection in another part of the body. Coming into contact with bacteria and developing an infection can trigger reactive arthritis. Chlamydia trachomatis is the most common bacteria that triggers Reactive arthritis.
Infective endocarditis (IE) is an infectious inflammation of the endocardium that affects the heart valves. The condition is a result of bacteremia, which is most commonly caused by dental procedures, surgery, distant primary infections, and nonsterile injections. From anamnesis, we understand that this patient is a drug addict and most likely uses non sterile injections. Clinical features include constitutional symptoms (fatigue, fever/chills, malaise) in combination with signs of pathological cardiac changes (e.g., new or changed heart murmur, heart failure signs). Notice that this patient has a pansystolic (holosystolic) murmur (usually heard in tricuspid valve regurgitation which can be one of the cardiac changes in IE).
Lutembacher syndrome is a very rare disorder that involves a congenital atrial septal defect coupled with an acquired mitral stenosis.
Recall that one of the major functions of the liver is detoxification i.e., converting harmful metabolites in the body into less harmful products that can be easily excreted out eg Ammonia is converted in the liver to urea which is then excreted via the urine. In a case of hepatic cirrhosis, this function of the liver is affected leading to the accumulation of harmful metabolites in the body system. Ammonia itself can easily cross the blood brain barrier causing encephalopathy. Notice that this patient presents with signs that suggest a reduction in mental activities.
Reye syndrome is a rare form of acute encephalopathy and fatty infiltration of the liver that tends to occur after some acute viral infections, particularly when salicylates (aspirin) are used.
This patient just experienced an Orthostatic syncope or collapse. She was in the horizontal position (lying down) and when she rose to the vertical (upright position) she fell down. Orthostatic syncope refers to syncope resulting from a postural decrease in blood pressure. Classic orthostatic hypotension occurs when there is a persistent reduction in blood pressure of at least 20mmHg systolic or 10mmHg diastolic within 3 minutes of standing or being upright.
When the body assumes an upright position, there is an immediate gravitational pooling of about 500 to 1000ml of blood to the lower extremities, splanchnic and pulmonary circulations. The decrease in venous return to the heart reduces cardiac output and eventually causes a drop in blood pressure. Baroreceptors in the carotid and aortic arteries sense this decrease in blood pressure and activate the sympathetic nervous system which leads to increased heart rate, systemic vasoconstriction, and increased cardiac muscle contractility all of which eventually increase blood pressure.
In a healthy individual, this sympathetic activation causes a physiological increase in heart rate by 10 to 20 bpm, diastolic blood pressure by 5mmHg, but minimal to no change in systolic blood pressure. In patients with autonomic dysfunction, there is an inadequate engagement of the autonomic nervous system in response to a decrease in blood pressure leading to persistent hypotension and in serious conditions just as we have here, it can result in collapse.
A peritonsillar abscess is a bacterial infection that usually begins as a complication of untreated strep throat or tonsillitis (4 days ago, the patient had a case of tonsillitis). also known as quinsy, it leads to the accumulation of pus due to an infection behind the tonsil. Key symptoms include; throat pain, difficulty swallowing , drooling , swelling of the face or neck, fever and chills. Notice that this patient presents with signs affecting the TONSILS; in a case of Pharyngitis, the posterior pharyngeal wall will be affected. In a case of infectious mononucleosis, Atypical lymphocytes will be present on analysis.
An etiotropic treatment is one aimed at the causative agent. In this case a Virus - Influenza A. Oseltamivir is an antiviral drug aimed at the treatment of influenza A and B. It acts by inhibiting influenza neuraminidase ( an enzyme needed for influenza replication). Zanamavir also has this function.
Acyclovir is also an antiviral drug used mainly in treatment of the herpes Simplex virus and Varicella zoster virus.
Scabies is a parasitic skin infestation caused by the Sarcoptes scabiei. It is characterised by intense pruritus (itching) at night; this characteristic and the location of the rashes helps us to diagnose scabies. The primary lessios found are usually papules, vesicles or burrows ( accompanied by excoriations and pustules) which are commonly seen in interdigital folds, flexor surfaces of the wrist, axillary folds, buttocks (closed areas of the body). Additionally in children, elderly persons, and immunosuppressed patients: scalp, face, neck, under the nail, palms of hands, and soles of feet.
Neurodermatitis is also referred to as Lichen simplex chronicus; it is chracterised by chronic itching and scaling localised on the wrist, neck, forearm, legs and anal region.
An aortic aneurysm is a localized pathologic dilation of the aorta; may cause abdominal and/or back pain which is a sign of leaking, dissection or imminent rupture. This patient is most likely having an aneurysm of the abdominal aorta which usually presents as a palpable abdominal pulsatile mass - Notice that in this patient, abdominal pulsation is observed coupled with a volumetric formation in the mesogastrium.
Acute cardiac aneurysm or a Cardiosclerotic aneurysm are common complications of a recent Myocardial Infarction. It refers to ventricular aneurysms which leads to decreased contractility of the heart and reduction of the flow of oxygen-rich blood to the body, causing heart failure and death. A cardiac aneurysm will rather show retrosternal symptoms instead of a mesogastric one as seen in this case.
From anamnesis, the patient is a fisherman by profession- with this we can assume that he consumes his primary product ( fish). Opisthorchiasis is a trematode (fluke) infection caused by infection with one of the species of the liver fluke Opisthorchis, which is acquired by eating raw or undercooked freshwater fish containing infectious metacercariae. The three species are: O. sinensis (still widely known as Clonorchis sinensis), O. felineus/tenuicollis and O. viverrini. Mostly asymptomatic but can present with dyspepsia, abdominal pain, diarrhoea or constipation. In the long term, we begin to observe hepatomegaly and malnutrition.
Trichinellosis is gotten after consumption of meat ( especially pork) infected by Trichinella spp. In this disease, the larva enters into the bloodstream and encysts in striated muscles leading to myositis ( a key finding).
The adult form of Taenia solium and T. saginata cause taeniasis, T. solium larvae cause cysticercosis. They are differentiated by the number of proglottids/ uterine branches 7-12 for T. solium and 17-35 for saginata.
Psoriasis is a common skin disorder characterized by the presence of papules and plaques with silvery scaling especially on the knees and elbows. Other characteristics include acanthosis, parakeratosis and pinpoint bleeding (Auspitz sign). The patient presents with a thimble symptom which translates into a pitting or a psoriatic nail.
A Panaritium or Whitlow is an acute purulent inflammation of the tissues of the finger or toes. Onychomycosis is a fungal infection of the nails; signs are white or yellow nail discoloration, thickening of the nail, and separation of the nail from the nail bed; it is also known as tinea unguium.
The signs and symptoms of riboflavin (vitamin B2) deficiency typically include sore throat with redness and swelling of the mouth and throat mucosa, cheilosis and angular stomatitis (cracking of the lips and corners of the mouth), glossitis, seborrheic dermatitis or pseudo-syphilis, and a decreased red blood cell count with normal cell size and hemoglobin content (normochromic normocytic anemia).
Thiamine (vit B1) deficiency is known as Beri-Beri, deficiency of ascorbic acid will lead to scurvy, easy bruising and bleeding are seen in such patients.
Observe that this patient presents pneumonia, high grade fever, low blood pressure and has been unable to urinate for the past 24 hours (which could be due to renal failure). This patient should be admitted to the intensive care unit; a urinary catheter should be inserted into the urethra in order to drain out the accumulated urine. After rectifying the issue of urinary flow, he can then be transferred to the pulmonology unit.
Ortner’s sign- tenderness on light percussion on right costal margin by the edge of the palm
Mayo-Robson’s signs- pain while pressing at the top of the angle lateral to the erector spinae muscles and below the left 12th rib left costovertebral angle.
These signs are present in a patient with pancreatitis and can be confirmed by the elevation of Diastase level. Urine diastase is useful in diagnosing uncertain abdominal cases (especially when pancreatitis is suspected).
From anamnesis, we observe that this patient works in a very hot/ steaming environment; the signs shown by this patient i.e., a red dry skin and a temperature of 39℃ indicates the effect of heat on the patient. Heat stroke is a form of hyperthermia in which the body temperature is elevated dramatically. The cause of heat stroke is an elevation in body temperature, often accompanied by dehydration.
The most common symptoms of CO (carbon monoxide) poisoning are headache, dizziness, weakness, upset stomach, vomiting, chest pain, and confusion on the background of inhalation of fumes from cars, generators etc.
Fetor hepaticus is a strong musty smell observed from the breath of a patient whose liver is failing to detoxify a toxic substance. An acute liver failure is observed when the liver loses its function within days or weeks. Note that this patient started experiencing the expressed symptoms a few hours after consuming mushrooms; it can also be caused by infection, alcohol or drug induced.
Cytolytic syndrome is a type of liver disease that leads in cell destruction; the major cause of this disorder is paracetamol overdose.
Hepatoliniel syndrome involves the reduction of kidney function accompanied by liver cirrhosis or liver failure.
The description - a single round erythematous focus 3cm in diameter, asbestos like scales accompanied by itching and hair loss on the affected area is typical for Ringworm (tinea capitis in this case) also known as Microsporai; an infection caused by microsporum fungi.
Differences between Ulcerative Colitis and Crohn Disease
Only colon involved
Continuous inflammation extending proximally
Skip-lesions with intervening normal mucosa
Inflammation in mucosa and submucosa only
Perinuclear ANCA (pANCA) positive
Occult blood in stool is indicative of a hemorrhagic process from the colon, while the results from the colonoscopy indicates the pathology is located in the colon.
Irritable bowel syndrome is an inflammatory bowel disease characterised by recurrent abdominal cramps (pain), change in form (consistency) and frequency of stool, constipation etc. . This condition is common in middle aged women and is associated with underlying conditions such as stress, anxiety, depression or a previous case of intestinal infection.
Note that Atypical lymphocytes are mostly associated with Infectious Mononucleosis, an infection obtained from the epstein barr virus (EBV). These lymphocytes are termed atypical because they have a larger cytoplasm and nucleoli in their nuclei. All other symptoms are generalised and can indicate every other disease.
It is stated that the patient has had this condition for 5 years; this rules out the possibility of an Acute form of the disease. The presence of an epigastric pain also confirms the answer isn't a Chronic enteritis. Pain and tenderness in the Mayo-Robson’s point indicates a pancreatic disorder. N/B Mayo-Robson's point – a point on the border of inner 2/3 with the external 1/3 of the line that represents the bisection of the left upper abdominal quadrant. This is where the tail of the pancreas is located.
Leptospirosis is an acute generalized infectious disease, characterized by extensive vasculitis, caused by spirochetes of the genus Leptospira. It presents with flu-like symptoms, myalgias ( majorly calf muscles eg gastrocnemius ), jaundice. Photophobia, icteric scleras etc. The icterohemorrhagic form of leptospirosis presents with a severe form of jaundice and azotemia from the liver and kidney dysfunction coupled with anemia.
N/B Virus hepatitis has a gradual onset, without chills, the temperature rises at the pre-icteric period. Muscle pains, scleritis, conjunctivitis are not characteristic of it. There are no meningeal and renal syndromes.
The initial symptoms of malaria infection are nonspecific and can include headache, nausea, vomiting, photophobia and muscle aches. A malarial paroxysm is marked by onset of a sudden shaking chill which may last from 10 to 15 minutes or perhaps longer. Elevated temperature accompanies the paroxysm and may be sustained for typically 10 hours or more. This cycle repeats itself every 36 to 72 hours depending on which species the human host has been infected with. The phase of erythrocytic schizogony takes place within day 6-15 of the disease ( patient arrives on Day 7); it is characterized by the production of merozoites which are released into the bloodstream.
Note that the toxins are covered with films that ‘cannot be easily removed’ in another term, the examiner might say ‘bleeds when removed’; these phrases are characteristic of a corynebacterium diphtheria infection. This bacteria produces a Diptheria toxin ( an Exotoxin).
The fact that the patient lost a lot of weight in a short period of time should signal a carcinogenic process. Key diagnostic features of this pathology include; blood in urine, presence of flank mass and pain accompanied with weight loss and high blood pressure; the dilated veins of the spermatic cord and scrotum (varices) is due to disrupted blood flow caused by increased pressure from the tumour.
A patient with urolithiasis will also experience flank pain, change in quantity of urine and can be differentiated by results from ultrasound. Glomerulonephritis will present with a nephrotic syndrome ( increased proteinuria accompanied by presence of edema).
Also known as Pott’s disease, lumbar tuberculous spondylitis is a medical condition caused by the hematogenous spread of tuberculosis mostly from the lungs; these spread contents are latter deposited in the spine- mostly the lower thoracic and upper lumbar vertebrae; they can also affect the intervertebral disc and generally cause symptoms of arthritis. Observe that from anamnesis, this patient has a history of tuberculosis and the various results from tests carried out shows a disruption in the normal form/functioning of the spine. A fracture will occur in case of trauma while osteochondrosis occurs mostly in developing individuals eg children and adolescents and is characterized by an interrupted blood supply to the bone especially the epiphysis of the bone.
Notice that the patient’s diastase level is high (norm: 25-125 U/L), diastase refers to groups of enzymes that catalyze the the breakdown of starch to maltose; these enzymes include α,β and γ amylase (especially α). The diastase level is useful in the diagnosing of diseases such as pancreatitis, jaundice, gall stones etc.
D-xylose test is a medical test performed to diagnose conditions that present with malabsorption (defect in GIT mucosa). In an individual with intact GIT mucosa, a 25 g oral dose of D-xylose will be absorbed and excreted in the urine at approximately 4.5 g in 5 hours ( it is 3.5g in this patient indicating a malabsorption syndrome).
Hemodialysis is a procedure used for removal of waste materials from the blood through filtration. It is carried out on people with renal failure. This patient experiences anuria ( production of only about 50-100ml of urine daily); creatinine levels are also rising; This procedure should be carried out to remove such waste products since the amount of urine being produced is inadequate.
Hypothyroidism is an endocrine disorder in which the thyroid gland does not produce enough thyroid hormones. It is classified under congenital and acquired. The acquired form is further divided into Primary, secondary and tertiary forms.
Primary Hypothyroidism: Occurs due to thyroid gland disturbances. This can be as a result of environmental factors, autoimmune causes e.g. Hashimoto, radiation etc. Characterized by low levels of T3 triiodothyronine and T4 thyroxine.
Secondary hypothyroidism: occur due to pituitary gland disorders. In this form, thyroid stimulating hormone (TSH) is low.
Tertiary Hypothyroidism: Occurs due to hypothalamic related disorders. Characterized by a low level of thyroid releasing hormone.
Symptoms include intolerance to cold, hair loss, fatigue, brittle nails, weight gain, bradycardia etc. sometimes referred to as Myxedema.
Prehepatic/ hemolytic - occurs due to increased breakdown of RBC eg, hemolytic disease of newborn. There is an increased level of unconjugated bilirubin. Stool and urine colour are normal.
Hepatic/ parenchymatous - Occurs in diseases affecting the liver parenchyma eg, cirrhosis, hepatitis etc. There is an increase in both unconjugated and conjugated bilirubin. Urine appears dark and faeces pale.
Post hepatic/ obstructive/ mechanical jaundice - pathology lies after conjugation of bilirubin and is caused by obstruction of biliary path. Conjugated bilirubin is accumulated, Urine is dark and faeces pale or acholic. Seen in disease such as cholelithiasis.
Ankylosing spondylitis (AS) is a chronic, multisystem inflammatory disorder primarily involving the sacroiliac (SI) joints and the axial skeleton. Overtime, it results in the fusion of the small bones in your spine (vertebrae) making the spine less flexible and can result in a hunched-forward posture. The term “swayback” is an inappropriate curve of the upper lumbar spine; And Bamboo spine is a radiographic feature seen in ankylosing spondylitis that occurs as a result of vertebral body fusion. Notice on X-ray ‘ankylosis of sacroiliac articulation, significant narrowing of intervertebral joint fissures of lumbar vertebrae and calcification of spinal ligaments’.
Urinary tract infections are commonly associated with dysuria, urinary frequency, urinary urgency and lumboabdominal pains.
When you have a UTI, the lining of the bladder and urethra become inflammed and irritated just as your throat does when you have phrayngitis, common cold - upper respiratory tract infections. The irritation can cause pain in your lower abdomen - pelvic area and even lower back, and will usually make you feel like urinating more often (false urges). Burning or pain when urinating is the most common symptom. You may even feel a strong urge or need to urinate but only get a few drops. This is because the bladder is so irritated that it makes you feel like you have to urinate, even when you don't have much urine in your bladder. UTIs can be found by analyzing a urine sample for Urine Microscopy/Culture/Sensitivity (Urine M/C/S). The urine is examined under a microscope for bacteria or white blood cells (leukocyturia), which are signs of infection. Blood can also be found in the urine sample (hematuria); this can be due to an infective or mechanical cause.
The other options given are more specific for kidney pathologies - proteinuria, gross hematuria, creatinine and urea. Rarely are they elevated in pathologies relating to Urinary Tract Infections except in cases where UTI’s become complicated and the kidney is affected after a prolonged and untreated UTI.
Ankylosing Spondylitis(AS) is a type of arthritis. It causes pain and stiffness, mainly in your spine. But it can also cause eye inflammation called uveitis. Left untreated, uveitis can harm your vision and, in some cases, lead to blindness.
Uveitis - An inflammation of the middle layer of the eye (uvea).
The most common type is an inflammation of the iris called iritis (anterior uveitis). If the ciliary body is also involved, it is called iridocyclitis.
About half of people with ankylosing spondylitis have uveitis at least once. It’s one of the most common complications of that form of arthritis.
Your eye doctor could actually be the first to figure out you have AS. That’s because the same inflammation that makes your back hurt can also cause inflammation in your eyes and other parts of your body.
Reactive arthritis is an inflammatory arthritis which manifests after several days to weeks after a gastrointestinal or genitourinary infection. It is also described as a classic triad of arthritis, urethritis and conjunctivitis. However, a majority of patients do not present with the classic triad. It was previously called "Reiter syndrome."
Conjunctivitis: purulent discharge from the eyes
Urethritis: painful burning sensations during urination
Arthritis: pain in leg joints
Reactive arthritis is known to be triggered by a bacterial infection, particularly of the genitourinary (Chlamydia trachomatis, Neisseria gonorrhoeae, Mycoplasma hominis, and Ureaplasma urealyticum) or gastrointestinal (GI) tract (Salmonella enteritidis, Shigella flexneri, and dysenteriae, Yersinia enterocolitica, Campylobacter jejuni, Clostridium difficile).
The classic triad can be remembered using this:
Conjunctivitis; Urethritis; Arthritis - Can’t See; can’t pee, can’t bend my knee
Cirrhosis is a complication of liver disease that involves loss of liver cells and irreversible scarring of the liver. The scarring is accompanied by loss of functioning liver cells. Cirrhosis is usually a late-stage disease of the liver that is not reversible in severe cases.
Hepatitis B, C, and chronic alcohol abuse are frequent causes (Question stem - patient takes alcohol excessively). Initially patients may experience fatigue, weakness and weight loss. During later stages, patients may develop jaundice (yellowing of the skin), gastrointestinal bleeding, abdominal swelling and confusion.
The most common cause of portal hypertension is cirrhosis of the liver. Portal hypertension is an increase in the blood pressure within a system of veins called the portal venous system. Veins coming from the stomach, intestine, spleen, and pancreas merge into the portal vein, which then branches into smaller vessels and travels through the liver. If the vessels in the liver are blocked due to liver damage, blood cannot flow properly through the liver. As a result, high pressure in the portal system develops.
Budd-Chiari syndrome is a condition in which the hepatic veins (veins that drain the liver) are blocked or narrowed by a clot (mass of blood cells). It may lead to portal hypertension, ascites, cirrhosis etc. Budd-Chiari syndrome can be caused by conditions and situations that cause your blood to clot (form a blockage) like sickle cell disease, pregnancy, myeloproliferative disorders. It is not caused by excessive alcohol intake or Hepatitis.
Hemochromatosis, Constrictive Pericarditis and Thrombosis of the splenic vein will not directly lead to portal hypertension.
Nikolsky's sign has been a very useful diagnostic tool in cases of skin disorders like pemphigus, toxic epidermal necrolysis, etc., The sign is demonstrated when lateral pressure is applied on the border of an intact blister, which results in the dislodgment of the normal epidermis and extension of the blister. For the Nikolsky sign in patients with active blistering, firm sliding pressure with a finger separates normal-appearing epidermis, producing an erosion. This sign is made possible due to the loss of cell-to-cell adhesion in the epidermis.
Acantholysis is the loss of intercellular connections, such as desmosomes, resulting in loss of cohesion between keratinocytes, seen in diseases such as pemphigus vulgaris. It is absent in bullous pemphigoid, making it useful for differential diagnosis. Hence, Nikolsky’s sign will be negative in non-acantholytic pemphigus.
Nikolsky's sign is pathognomonic for pemphigus, toxic epidermal necrolysis, and staphylococcal scalded skin syndrome (SSSS). This sign basically differentiates intraepidermal blisters from subepidermal blisters.
Toxicoderma are usually caused by drugs and this patient has no history of taking any medication that would have resulted in toxicoderma. Dermatitis herpetiformis is an autoimmune blistering disorder associated with a gluten-sensitive enteropathy (patient wasn’t diagnosed of celiac disease). Herpes usually presents as grouped vesicles, meanwhile, on examination of the patient isolated vesicles were detected.
The question specifies that the described lady is Depressed therefore, antidepressant is the best choice among the listed groups. Antipsychotic drugs/neuroleptics are used in cases of Schizophrenia or bipolar disorders. Nootropics are memory enhancing drugs.
Examples of antidepressants:
Tricyclic antidepressants: Amitriptyline, Imipramine
Monoamine oxidase inhibitors: Selegiline
Selective Serotonin reuptake inhibitors: Fluoxetine, Paroxetine, Sertraline
Serotonin-Norepinephrine reuptake Inhibitors: Venlafaxine, Duloxetine
It is important to note that certain drugs can be used for the diagnosis of Pheochromocytoma (a tumor of the adrenal medulla). The Histamine test was the first test introduced and later on drugs such as piperoxan, tetraethylammonium bromide, methacholine chloride and phentolamine hydrochloride (Regitine) were added. Histamine, tetraethylammonium bromide, and methacholine chloride (Mecholyl) stimulate the discharge of the pressor substances from the tumor. Thus, tests with these drugs are useful in cases of paroxysmal hypertension to produce attacks similar to those that occur spontaneously. Phentolamine (Regitine) and piperoxan (Benzodioxane), on the other hand, lower blood pressure by blocking the pressor effect of epinephrine and norepinephrine in the blood if a pheochromocytoma is present.
Basically, in this patient we are looking for a medication that will take care of all the conditions - atrial fibrillation and heart failure.
Digoxin is a cardiac glycoside used to treat atrial fibrillation, mild to moderate heart failure in adults, and heart failure in children. Digoxin belongs to a class of drugs called antiarrhythmics. It works by slowing your heart rate down and improving the way your ventricles are filled with blood. In patients with heart failure, it increases contractility and in Atrial fibrillation, it decreases conduction at AV node and depression of SA node.
Verapamil: Class IV antiarrhythmic drug - calcium channel blocker. It is contraindicated in patients with heart failure.
Ivabradine: mainly used to treat heart failure conditions.
Procainamide: Class I antiarrhythmic drug - sodium channel blocker. It can be used for both atrial and ventricular arrhythmias but not heart failure.
Your doctor may recommend a thyroid scan to help evaluate thyroid nodules. During this test, an isotope of radioactive iodine is injected into a vein in your arm. You then lie on a table while a special camera produces an image of your thyroid on a computer screen.
Nodules that produce excess thyroid hormone — called hot nodules — show up on the scan because they take up more of the isotope than normal thyroid tissue does. Hot nodules are almost always non-cancerous.
In some cases, nodules that take up less of the isotope — called cold nodules — are cancerous.
Therefore, the best choice here is Thyroid Cancer, as the scanning image shows a “cold nodule.”
Diffuse toxic goiter or grave’s disease is an autoimmune disease characterised by an increased amount of thyroid hormones ( T3- triiodothyronine and T4- thyroxine). Symptoms include; loss of weight, with increased appetite, increased sweating, cardiac findings (tachycardia, increased risk for atrial fibrillation), tremors of extremities, heat intolerance, diarrhea, anxiety etc.
It is the most common cause of hyperthyroidism and more common in females than males. There is production of IgG antibodies against the TSH receptor (stimulating type of antibody - Type II hypersensitivity reaction)
Hashimoto’s thyroiditis is a destructive autoimmune thyroiditis leading to hypothyroidism.
Leptospirosis is an acute generalized infectious disease, characterized by extensive vasculitis, caused by spirochetes of the genus Leptospira. It presents with flu-like symptoms, myalgias (majorly calf muscles eg gastrocnemius), jaundice (icteric face), Photophobia etc. The icterohemorrhagic form of leptospirosis presents with a severe form of jaundice and azotemia from the liver and kidney dysfunction coupled with anemia. Leptospira is commonly found in water contaminated with animal urine.
N/B Virus hepatitis has a gradual onset, without chills, the temperature rises at the pre-icteric period. Muscle pains, scleritis, conjunctivitis are not characteristic of it.
Brucellosis is caused by gram negative bacteria, transmitted via ingestion of contaminated animal products (eg, unpasteurized milk). Typically presents with fever, night sweats, and arthralgia but jaundice is usually absent.
Cutaneous anthrax, the most common form of naturally occurring disease, begins as a small, painless, pruritic papule that within 2 days enlarges, develops vesicles, and ulcerates to form an eschar. Inhalational anthrax follows inhalation of infectious doses of anthrax spores.
Meningitis is an acute infectious disease with involvement of the arachnoid and pia mater of the brain and spinal cord by pathogenic microorganisms. Etiologically, the various forms include; bacterial, viral. Fungal and tuberculous meningitis. The tuberculous form occurs as a secondary infection (from anamnesis, the patient already suffers from pulmonary tuberculosis).
The classic triad of fever, headache, and neck stiffness (nuchal rigidity) is usually present.
The term subarachnoid hemorrhage (SAH) refers to extravasation of blood into the subarachnoid space i.e. the space between the pia and arachnoid membranes.
The subarachnoid space is the space where the cerebrospinal fluid (CSF) circulates, therefore, hemorrhage into this space will result in bloody CSF as mentioned in the question. The CSF is responsible for protecting your brain from injury by serving as a cushion. A hemorrhage in this space can cause a coma, paralysis, and even death. It is often characterized by a severe headache (often referred to as ‘worst headache of my life’).
Severe headaches and bloody CSF are the hallmarks for making Subarachnoid hemorrhage diagnosis especially in patients with Severe Hypertension.
The most common cause of primary Subarachnoid Hemorrhage is a berry aneurysm. These aneurysms swell up and weaken the walls of the arteries over time. Brain aneurysms are more common in smokers, and in those with elevated blood pressure. In some cases, trauma to the brain during an injury can cause aneurysms and result in a subarachnoid hemorrhage.
Main causes and risk factors
Almost always caused by rheumatic heart disease
-Calcification of tricuspid aortic valve with age
-Calcification of bicuspid aortic valve
Hypertension, diabetes mellitus, hyperlipoproteinemia and uremia may speed up the process.
-Primary valvular: rheumatic fever, bicuspid aortic valve, Marfan's syndrome, Ehlers–Danlos syndrome, ankylosing spondylitis, systemic lupus erythematosus
-Disease of the aortic root: syphilitic aortitis, osteogenesis imperfecta, aortic dissection, Behçet's disease, reactive arthritis, systemic hypertension
-Endocarditis, mainly S. aureus
-Papillary muscle rupture or dysfunction, including mitral valve prolapse
Usually secondary to right ventricular dilation
Other causes: Tricuspid endocarditis, rheumatic fever, Ebstein's anomaly, carcinoid syndrome and myxomatous degeneration