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Blast cells are immature WBC. Presence of 32% of Blast cells in the analysis indicates an acute form of leukemia. Less than 10% of blast cells will indicate a chronic form. This patient also has an anemia (post hemorrhagic form) indicated by the low level of RBC. N/B, when there is leukemia, most of the immature cells will be recruited to produce the cancer cells which will cause a reduction in most of the other cell types especially RBC’s.
Antipsychotic drugs (neuroleptics) are a group of medications used in patients with psychosis ( hallucination, disorder in thought, paranoia or delusions). This patient is agitated and is having auditory hallucinations therefore an antipsychotic therapy is needed. Tranquilizers are used in anxiety disorders, fear, tension etc. Nootropics are drugs used in boosting memory and creativity.
The essential features of Panic Disorder are recurrent attacks of severe anxiety (panic attacks) which are not restricted to any particular situation or set of circumstances.
Typical symptoms are palpitations, chest pain, choking sensations, dizziness, and feelings of unreality (depersonalisation or derealization). Individual attacks usually last for minutes only.
Manic syndrome is characterised by an elevated, expansive or irritable mood, an increased psychomotor, speech and thought activities coupled with an unusual alertness, trying to do many things at one time.
Paranoid personality disorder is a personality disorder characterized by intense mistrust and suspicion of others.
Gestational pyelonephritis is a urinary tract infection that occurs in pregnant women. It is caused by bacteria that is why on blood analysis, we see leukocyturia. It is also accompanied by signs of pyelonephritis which include dysuria, lumbar pain, fever etc
Cystitis is an inflammation of the bladder, characterised by frequent urge to urinate, blood in urine, pain during intercourse etc. Pyelitis is an inflammation of the renal pelvis.
Bronchiectasis is a chronic necrotizing infection of the bronchi and bronchioles leading to or associated with abnormal dilation of these airways. Symptoms include cough and daily mucopurulent sputum production, often lasting for months; blood-streaked sputum (hemoptysis), dyspnea, low grade fever, pleuritic chest pain, wheezing, fever, weakness, fatigue and weight loss. Presence of moist crackles on auscultation indicates an infectious or inflammatory process; digital clubbing is seen in 2-3% of patients. A dilated and deformed left pulmonary root confirms bronchiectasis of the left lung.
Lung abscesses are characterized by large cavities filled with suppurative debris.
The patient presents with weak dropping hands and a weakened carporadial reflex; this sign is often seen in individuals poisoned by lead ( wrist and foot drop). Other major signs are ’ Lead lines’ on gingiva/gums ( Burton's line),abdominal colic, encephalopathy and sideroblastic anemia.
Guillain-Barre syndrome is an autoimmune condition that destroys schwann cells via inflammation and demyelination of nerve fibres. It occurs as a result of molecular mimicry and triggered by infections, stress etc. major signs include Bilateral facial paralysis and respiratory failure.
Shingles is gotten from varicella zoster virus infection.
A toxic goiter refers to goiters which cause Hyperthyroidism eg. diffuse toxic goiter. A non toxic goiter does not cause hyperthyroidism - it refers to a diffuse or nodular enlargement of the thyroid gland that does not result from an inflammatory or neoplastic process and is not associated with abnormal thyroid function.. Notice that this patient shows symptoms of hyperthyroidism (loss of weight, tachycardia); this rules out the option of a non-toxic goiter. Nodular goiter is palpated as painless tumour with regular contours, smooth surface, not connected with adjacent tissues and displaced during swallowing. In this patient, the node on the left lobe coupled with signs of hyperthyroidism indicates a nodular goiter.
A breast abscess is a localised collection of pus in the breast tissue. It is usually caused by a bacterial infection. It is characterised by the presence of a lump on palpation (painful infiltrate can be palpated), swollen and painful nipple.
In mastopathy, we observe changes such as swellings, nodules, cysts etc, it is hormone dependent. In cancer, there will be increased proliferation of atypical tissues.
Sarcoidosis is an inflammatory disease in which granulomas, or clumps of inflammatory cells, form in various organs. This causes organ inflammation. The lungs and lymph nodes are the most affected areas. The absence of caseous necrosis, rules out the option of lymph node tuberculosis while in Lymphogranulomatosis, we see Reed-sternberg cells which are a different type of giant cell from these granulomas. Infectious mononucleosis is characterized by Atypical lymphocytes.
Biliary and renal colic refer to pain that occur as a result of the blockage(most especially by stones) of the biliary or urinary tract respectively. This severe pain is due to continuous spasms (involuntary contraction) against these stones. To salvage this situation, the patient should be prescribed a spasmolytic (to stop the spasms) and an analgesic ( for pain relief).
Psoriasis is a common skin disorder characterised 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.
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.
Distinguishing Ulcerative Colitis from 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
An ultrasound of the lesser pelvis is used to examine the organs of the pelvis; in females these include the uterus, cervix, vagina, fallopian tubes and ovaries. The above patient has issues with the uterine appendages and this diagnostic method will be the most informative among all listed.
A colposcopy is a simple procedure used to look at the cervix, the lower part of the womb at the top of the vagina.
In the case of a pleural effusion, there can be different types of fluids; Transudate and Exudate. A transudate is due to high capillary pressure and has protein levels below 25g/l or 2.5g/dl while an exudate is mostly present in inflammatory processes and its protein content is above 25g/l or 2.5g/dl.
Mondor’s sign refers to the presence of violet spot on face and trunk; Cullen’s sign refers to the yellow coloring of skin around the umbilicus; Mayo-Robson sign is the feeling of pain when pressure is applied by the fingers in the left costo-vertebral angle. These signs are seen in an individual with pancreatitis. Also notice that the patient experiences pain in her epigastric and left subcostal areas with irradiation to the back; this rules out the option of cholecystitis in which the pain is present in the right upper quadrant.
Acute laryngitis is catarrhal inflammation of mucous membrane, sub mucous layer and internal muscles of larynx. Clinical picture involves Feeling of dryness, burning, tickling sensation, A dry, then moist cough, Hoarse voice. The above patient presents with a dry sensation, pain while swallowing, a hyperemic larynx and viscous (purulent ) secretion which confirms an acute laryngitis ( chronic form typically lasts more than 3 weeks).
Acute laryngotracheitis (croup) is a common viral infection which generally affects children younger than 5 years of age. Causative agents include Parainfluenza, influenza, rhinovirus etc. Stridor and steeple sign ( subglottic narrowing) are common signs.
A biophysical profile is a prenatal test used to check the well being of a baby. It involves using an ultrasound in evaluating the fetal heart rate, breathing, movement ,muscle tone and amniotic fluid level combined with a non-stress test for checking the fetal heart rate. Points are allocated for every measurement taken. This test is recommended for pregnant women at high risk of complications and a tendency of pregnancy loss. In most cases, a low biophysical profile score might indicate an early or immediate child delivery.
Note that the score of the above profile is 4 (indicating an immediate delivery).
A colposcopy is a simple procedure used to look at the cervix, the lower part of the womb at the top of the vagina ( Colposcopy is like a microscope put near the vagina to allow more detailed examination of the cervix). It's often done if cervical screening finds abnormal cells in your cervix. Under the guidance of colposcopy, a piece of the lesion will be removed (called a biopsy) and sent to the laboratory for detailed examination.
A hysteroscopy is used in detecting pathologies involving the Uterus. Curettage is a procedure used in removing tissues from the uterine cavity.
Basically, there are three forms of cancer of the uterus (endometrium):
Fibrous carcinoma or scirrhous, hard cancer
Medullary or encephaloid, or soft cancer
epithelioma, or chancroid.
Observe that on curettage of the uterine cavity, an encephaloid matter was found thereby indicating the presence of an endometrial (uterine) carcinoma.
Adenomyosis is a condition that involves the encroachment, or movement, of the endometrial tissue that lines the uterus into the muscles of the uterus. This makes the uterine walls grow thicker. It may lead to heavy or longer-than-usual menstrual bleeding, as well as pain during your menstrual cycle or intercourse.
Gout is an inflammatory arthritis characterized by self-limiting but excruciatingly painful acute attacks. These are a consequence of monosodium urate (MSU) crystal deposition within articular or periarticular tissue. Uric acid ------►Crystals------►Crystals deposits in joint------►Joint inflammation; the metatarsophalangeal are mostly affected. Hyperuricemia is a key finding in gout; notice that the patient’s uric acid level is 720mcmol/l ( norm: Male: 0.12-0.38 mcmol/L, Female: 0.12-0.46 mcmol/L).
Osteoarthritis is characterised by both degeneration of articular cartilage and simultaneous proliferation of new bone, cartilage and connective tissue.
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, increased sweating,tachycardia, tremors of extremities, increased appetite etc.
Hashimoto’s thyroiditis is a destructive autoimmune thyroiditis leading to hypothyroidism.
A nontoxic goiter is a diffuse or nodular enlargement of the thyroid gland that does not result from an inflammatory or neoplastic process and is not associated with abnormal thyroid function.
Acute Urinary Retention is a Sudden inability to urinate. The patient experiences increasingly agonizing suprapubic pain associated with severe urgency and may dribble (release) only small amounts of urine. Urinary retention is characterised by poor urinary stream with intermittent flow, straining, a sense of incomplete voiding, and hesitancy (a delay between trying to urinate and the flow actually beginning). As the bladder remains full, it may lead to incontinence, nocturia (need to urinate at night), and high frequency. Notice that this patient has only had this for 8 hours (a short period); in the chronic form, it might last for days and also be recurrent.
paradoxal Ischuria is a form urinary incontinence that occurs when the bladder is so full that it continually leaks urine; often attributable to a blocked urethra (e.g., due to prostate enlargement) or weak bladder muscles or nerve damage.
After the x-ray was carried out with an uncertain result, a transbronchial biopsy with cytologic investigation was carried out and the result was a glandular neoplasm ( a tumor from the glands). With this known, a chemotherapeutic approach should be taken ( ie, drugs targeted at killing fast differentiating cells in the body).
From anamnesis, we see that the patient experienced a prolonged Menstrual cycle characterized by profuse blood discharge; the current state of the patient (pale skin, fatigue etc) is due to the amount of blood already lost. A post hemorrhagic anemia is a condition in which a person loses lots of hemoglobin and RBCs due to blood loss. It is usually seen in cases of trauma, severe injuries etc.
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.
Deep vein thrombosis is observed when a clot is formed in a blood vessel located deep in the body ( not a superficial vessel). 3 factors (virchow’s Triad) that are critically important in the development of venous thrombosis: (1) venous stasis, (2) activation of blood coagulation, and (3) vein damage. Signs include throbbing or cramping pain, swelling, warm skin around the painful area, red or darkened skin, swollen veins etc. Note that in varicose veins, it is the superficial veins that are being affected (caused mainly due to an increased venous pressure) and can be clearly visible on the surface of the skin as twisted and enlarged.
Rh Antibody Titre test is done to determine the type and quantity of antibodies in the blood. Rh antibodies are likely to rise during pregnancy. Depending on the level of other antibodies these antibodies could cause hemolytic problems in the baby and need to be monitored. It is usually repeated several times during pregnancy (at 32, 36, & 38 weeks). A low titer (less than 1:16) may not pose any problem for the baby. any test from 1:64 or higher, is indicative of incompatibility. Notice that the patient has previously had 2 fetal deaths from this incompatibility, to save the current situation, an early delivery should be induced.
Congestive heart failure can cause both peripheral, pulmonary and abdominal edema (ascites). This is because the heart is too weak to pump blood around the body properly, so the blood gathers in front of the heart. Because of this, and due to the increased blood pressure in the veins, fluid seeps out into the surrounding tissue. This may cause swelling in the legs or a build-up of fluid in the abdomen. A rasping systolic murmur also indicates an organic heart pathology.
Nephrotic syndrome also leads to edema but will be characterised by severe proteinuria and an increased depletion in albumin levels.
Angioneurotic edema is seen in individuals with deficiency in C1 esterase inhibitor deficiency. It is also referred to as quinke’s edema.
Edema as a result of hepatocirhosis will be seen in an individual with a chronic alcohol abuse history or one with a liver related pathology.
ErbDuchenne palsy is the paralysis of the arm caused by the injury to the nerves C5-C6. Paradoxical respiration is a term used to refer to distressed breathing. Notice that this patient's left lung lags behind during respiration and respiration is also weakened on this side; a paresis ( muscular weakness due to nerve damage) of the diaphragm (the main respiratory muscle) can lead to this situation.
No changes in CBC rules out the option of an infection ( congenital pneumonia) and respiratory distress is often seen in preterm babies with lack of sufficient surfactant.
Primary prophylaxis involves the treatment of streptococcal pharyngitis with antimicrobial therapy.
Secondary prophylaxis involves Continuous prophylaxis in patients with well-documented histories of rheumatic fever and in those with evidence of rheumatic heart disease. The table below gives the guideline:
Duration after last attack
Rheumatic fever with carditis and residual heart disease (persistent valvular disease†)
10 years or until age 40 years (whichever is longer); lifetime prophylaxis may be needed
Rheumatic fever with carditis but no residual heart disease (no valvular disease†)
10 years or until age 21 years (whichever is longer)
Rheumatic fever without carditis
5 years or until age 21 years (whichever is longer)
Pay attention to the Hemogram and notice that the lymphoblast level is highly elevated. Leukemia is a cancer of the marrow and blood. The major forms of leukemia are divided into four categories. The terms myelogenous or lymphocytic denote the cell type involved. Myelogenous and lymphocytic leukemia each have an acute or chronic form. Thus, the four major types of leukemia are acute or chronic myelogenous and acute or chronic lymphocytic leukemia. Acute leukemia is a rapidly progressing disease that affects mostly cells that are unformed or immature (Blast cells). These immature cells cannot carry out their normal functions. Chronic leukemia progresses slowly and permits the growth of greater numbers of more developed cells.
In thrombocytopenic purpura there will be a decreased number of circulating platelets (thrombocytopenia), easy bruising (purpura), or extravasation of blood from capillaries into skin and mucous membranes (petechiae).
Notice that mucosal walls are retained and wall peristalsis and elasticity are not affected- these rule out the options of achalasia cardia, Esophageal burns and barrett's esophagus ( because in these pathologies, one or more of the above listed is/are affected). The result from the x-ray shows a mass with clear oval borders thereby indicating a tumour.
Achalasia Cardia is a rare neurodegenerative disorder of esophagus resulting in defective peristalsis and impaired relaxation of lower esophageal sphincter. In Barrett's esophagus, the mucosal lining transforms from normal stratified squamous epithelium to simple columnar epithelium.
Pseudofurunculosis, is observed in neonates and infants. The disease begins with the appearance of superficial pustules in the ostium of sweat glands (periporitis). Caused by staphylococcus aureus, which penetrates in the depth of the sweat gland and causes the forming of deep indurated painful nodules. The nodules are very similar to furuncles, but they have not got core in the center (hence the name pseudofurunculosis).
Vesiculopustulosis is a widespread purulent disease, which appears in the first years of life. In the ostium of the sweat glands numerous pustules appear, filled with white yellow matter, the size of a pin head to a small pea, they do not merge with each other and are surrounded by bright edematous circles
The patient presents with deep vein thrombosis, swollen cervical veins; this implies that we have to use an investigative method that will help us visualize inside the blood vessels. Selective angio pneumography is a diagnostic method that helps visualize the lumen of blood vessels and organs. I.e., veins, arteries, chambers of the heart.
Enterovirus infections (ECНO and Coxsackie’s infections) a group of an acute diseases caused by ECНO and Coxsackie’s enteroviruses, that are characterized by the variety of clinical displays from the mild fever and simple carrying of virus to protracted meningoencephalitis, myocarditis, myalgia and other. Notice that the cell count in the CSF is 90% lymphocytes which indicates a viral cause; for bacterial origin, the cell count will be mainly neutrophils. Enterovirus is the only viral cause amongst the listed agents.
An adenoma is a benign epithelial tumor from the epithelium of the glands and glandular organs e.g. breast, thyroid gland, ovaries etc. A fibroadenoma is a benign nodular proliferation and not a true neoplasm (cancer); it presents as a mobile lump in the breast of young women.
Lactocele are breast cysts that develop during or after lactation and are characterised by the accumulation of milk.
Diffuse mastopathy is a Fibrocystic change of the breast (also known as diffuse cystic mastopathy) is a benign alteration in the terminal ductal lobular unit of the breast with or without associated fibrosis.
A Troacar cystostomy or suprapubic catheter is a surgical connection made between the urinary bladder and the skin, it is carried out in individuals experiencing urinary blockade even after the use of a catheter.
Optical Internal Urethrotomy is used to treat urethral strictures, a medical condition when the urethra (the tube that drains urine from the bladder) becomes narrow. In this surgical process, the body tissues in the urethra are removed, to release it.
Pheochromocytoma is a tumor of the adrenal medulla; it stimulates the increased production of catecholamines. vanillylmandelic acid is an end stage metabolite of catecholamines and is typically elevated in patients with catecholamine-secreting tumors (eg, neuroblastoma, pheochromocytoma, and other neural crest tumors)......
The function of the alveoli is dependent on the alveolar wall which is a thin membrane, allowing for oxygen and carbon dioxide to move freely across it. Notice that on auscultation, the patient presents with cellophane-type crackles which indicates an interstitial lung disease. Results from spirometry show a restrictive lung disease which rules out the options of COPD and chronic bronchitis ( which are obstructive lung diseases). IFA is a disease affecting both the walls and the interior of alveoli. It causes fibrosis of the alveolar walls, which impairs gas exchange.
A neuroleptic is an antipsychotic drug used that targets a patient's cognition and behaviour. In psychotic patients, neuroleptic drugs cause a reduction in confusion and agitation and tend to normalize psychomotor activity. This patient also has a reduced need for sleep therefore, he should also be given a neuroleptic that can assist in sleeping (with sedative effect). Tranquilizers are used in anxiety disorders, fear, tension etc. Nootropics are drugs used in boosting memory and creativity.
Our first approach should be to stop the bleeding which is done by applying a tourniquet above the injury.
Berezovsky/Reed-Sternberg (RS) cells are giant cells that have more than one nucleus and appear large, eosinophilic, inclusion-like nuclei. The lineage of these cells is probably B-cell lymphocytes. RS cells and the accompanying mononuclear Hodgkin’s cells are the neoplastic cells in Hodgkin’s lymphoma (lymphogranulomatous), surrounded by a reactive cellular infiltrate. RS cells usually express CD15 and CD30 (Ki-1, an antigen that is also expressed in anaplastic large cell lymphoma).
Lymph node tuberculosis is one of the extra pulmonary forms of Tb. The lymph node TB usually causes a painful swelling of one or more lymph nodes. Most often, the disease is localized to the anterior or posterior cervical chains (70-90%) or supra clavicular. It is often bilateral and non-contiguous lymph nodes can be involved
Cryoprecipitate is also known as cryoprecipitated antihemophilic factor. It is prepared from plasma and contains fibrinogen, von Willebrand factor, factor VIII, factor XIII and fibronectin. Used to prevent or control bleeding in people whose own blood does not clot properly. This includes patients with serious but rare hereditary conditions such as Hemophilia A (who lack factor VIII) and von Willebrand disease (who lack von Willebrand factor.
Fresh frozen plasma contains all factors of the soluble coagulation system, including the labile factors V and VIII. FFP is indicated when a patient has Multiple factor deficiencies and is Bleeding.
Notice that the result of the CT shows a bulky mass in the sella; anatomically, the pituitary gland is located in the sella turcica of the sphenoid bone and a bulky formation of such diameter in this location indicates the presence of a tumour. Furthermore, Prolactin levels are twice the normal; this hormone is produced from lactotrophs present in the anterior pituitary gland. The increased production is mostly as a result of the tumour.
Lactational amenorrhea is observed in breastfeeding mothers; the period after child birth in which the lactating mother doesn't menstruate.
Polycystic ovarian syndrome is a disorder found in women of reproductive age commonly due to hormonal disorder (high level of androgens). This disorder is characterised by infrequent menstrual cycle, pelvic pain, weight gain etc. The ovaries mostly develop follicles (collection of fluids).
From ultrasound, we observe the reduction in size of the right kidney; this may be due to a reduction in blood flow or a chronic infection ( as earlier stated, she previously had a case of pyelonephritis). Due to the constriction of the renal artery, the kidney releases Renin (from juxtaglomerular cells). This renin converts angiotensinogen (produced in the liver) to angiotensin I; Angiotensin I is then converted to angiotensin II by angiotensin converting enzyme, ACE ( an enzyme produced in the vascular endothelial cells of the lungs). Angiotensin II then stimulates the secretion of aldosterone from the adrenal cortex. In this system, angiotensin II is a potent vasoconstrictor that assists in the Increase of blood pressure.
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.
Realise that the above symptoms began after the hemotransfusion. These signs are related to an acute hemolytic reaction which occurs due to ABO incompatibility. This is further proven by the presence of dark urine which is as a result of the broken down RBCs. An acute hemolytic reaction is one of the leading paths to the development of a post transfusion shock.
An anaphylactic shock during hemotransfusion will mostly occur in individuals with IgA deficiency.
Acute renal failure refers to a significant reduction in renal function occurring over hours or days clinically manifesting as an abrupt and sustained rise in serum urea and creatinine levels.
Rheumatoid Arthritis is an autoimmune inflammation of the joints; it is usually symmetric,accompanied by pain, swelling, morning stiffness lasting greater than 1 hour and improves with continuous use.
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. Characterised 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. Characterised 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.
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.
Spondylitis deformans is characterised by degeneration in the intervertebral discs followed by the presence of bony spurs or osteophytes along the edges of the bones of the spine.
An echocardiography is a procedure used in checking the live images of the heart. Information from this procedure shows: Changes in your heart size, Pumping strength, Damage to the heart muscle, Valve problems, Heart defects.
An electrocardiography is a procedure that records electrical signals of the heart. It provides information about the heart rate, rhythm, Inadequate blood and oxygen supply to the heart, Heart attack and some structural abnormalities.
A phonocardiography is the recording of the sounds from the heart.
The above patient has a pathology regarding the organs of the thoracic cavity. A diagnostic procedure involving an ultrasound of the abdomen will not help in confirming the diagnosis.
Note that after the hypertensive crisis, the patient is presenting with symptoms that shows she is progressing into a comatose state. The absence of edemas or smell of acetone shows the patient is still in a stable condition; inorder to prevent the development of a diabetic coma, metformin should be replaced by short acting insulin such as Aspart, lispro etc.
Metformin (Glucophage) is an oral diabetic drug indicated for the treatment of type 2 diabetes and polycystic ovarian syndrome. It is a biguanide which prevents the further production of sugar from the liver and improves the body's sensitivity to insulin.
According to the Criminal Procedure Code currently in force in Ukraine, forensic medical examination is required to determine the cause of death.
Involution is the term used to describe the physical reduction in size of the uterus and cervix after parturition (childbirth). This process begins immediately after expulsion of the placenta with contraction of the uterine smooth muscle. The uterus, which at full term weighs approximately 11 times its prepregnancy weight, involutes to approximately 500 g by 1 week after birth and to 350 g by 2 weeks after birth. At 6 weeks it weighs 50-60 g.
Subinvolution is the failure of the uterus to return to a nonpregnant state. The most common causes of subinvolution are retained placental fragments and infection.
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).
Irritable bowel syndrome is a disorder of the large intestine related to defecation, change in stool frequency and form. Patients with IBS will present with no structural abnormality, but will experience changes in the pattern of bowel movements.
An outlet forceps is used in assisting delivery when there is full cervical dilation with the fetal head reaching the perineal floor and the scalp is visible between contractions. This type of assisted delivery is performed only when the fetal head is in a straight forward or backward vertex position or in slight rotation (less than 45 degrees to the right or left) from one of these positions.
The patient in question is manifesting signs and symptoms of pre-eclampsia already: proteinuria 3.3g/L; elevated blood pressure 180/100mmHg; headache and seeing spots; pregnancy is already beyond 20 weeks of gestation. The fetus is still stable judging from the fetal heart rate of 140beats per min. So, with a full cervical dilation, the best option is to assist the delivery using an outlet forceps.
Full cervical dilatation indicates completion of the first stage of labor and if the head of the fetus has descended, then an assisted vaginal delivery can be pursued without much risk to both the mother and fetus.
With a full cervical dilatation (completion of the first stage of labor) and in the absence of fetal distress, a cesarean section will be unnecessary. Cavity forceps and Vacuum extraction can be used when the head of the fetus is still high up in the uterus (i.e. yet to descend) or in the case of a retained second twin in multiple gestation.
We can’t go for the option of conservative labor management in this condition because the patient is already showing signs of pre-eclampsia and delivery should be done promptly.
The contact with chemicals led to the edematic reaction in the worker’s larynx. Recall that the larynx is the voicebox; this is why the edematic reaction presents with symptoms such as stridor, voice hoarseness, barking cough etc/.
The options of Neisseria gonorrhoeae, Staphylococcus aureus , Trichomonas vaginalis and chlamydia trachomatis can all lead to an Adnexitis which refers to a disease of the female genital organs that causes inflammation of the uterus, ovaries and fallopian tubes. But notice that on further examination, diplococci with intracellular and extracellular position were found- this characteristic is typical for Neisseria gonorrhoeae which is a gram negative diplococci.
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 either a nephritic ( hematuria, slight proteinuria and hypertension) or nephrotic syndrome ( increased proteinuria accompanied by presence of edema).
Myocarditis is an inflammation of the myocardium, it presents with a disruption in heart conduction and abnormal heart rhythms (arrhythmia). Notice that the above patient experiences an arrhythmia and the results from auscultation and percussion indicates an inflamed portion of the heart. From anamnesis, the patient has a respiratory infection; many infectious, metabolic, toxic, inflammatory processes can lead to a myocarditis- the infectious form is mostly caused by a viral infection.
Hypertrophic cardiomyopathy (HCM) is a disease in which the heart muscle becomes abnormally thick (hypertrophied). The thickened heart muscle can make it harder for the heart to pump blood.
It is well noted that on examination, the patient presents with ‘Meningeal Symptom’ (stiff neck, sensitivity to light etc). To understand the cause of these meningeal signs, a lumbar puncture is carried out inorder to obtain the cerebrospinal fluid for analysis.
A lumbar puncture, also known as a spinal tap, is a medical procedure in which a needle is inserted into the spinal canal, most commonly to collect cerebrospinal fluid for diagnostic testing. The main reason for a lumbar puncture is to help diagnose diseases of the central nervous system, including the brain and spine.
Syphilis is a sexually transmitted disease caused by the spirochete Treponema Pallidum. It has three stages namely:
Primary stage is characterised by the presence of Hard Chancre which are firm, painless genital ulcers/ sores. Lymphadenitis and Lymphagitis are also seen in this stage.
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.
Candidiasis is also known as vaginal thrush or vaginal yeast infection. It is characterised by very severe vaginal itching, burning sensation while urinating, pain during sex, hyperemic vagina and a thick white vaginal discharge
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).
Pityriasis rosea is a viral rash that resembles small oval red patches and are very itchy.
Results from the microscopy of smears coupled with the complaints of painful urination and discharge indicates an infection by Neisseria gonorrhoeae ( a gram negative diplococci). The result from the bacteria smear presentation rules out the options of Chlamydia, candida and trichomonas. The infection is an acute one since the individual has only experienced it for about a week.
Schizophrenia is a mental disorder characterised by disturbances in thought and verbal behaviour,perception, motor behaviour and relationship to the external world. The different clinical types include; Paranoid, disorganised/ hebephrenic, Catatonic, residual or latent, undifferentiated schizophrenia. The described patient is said to have a paranoid schizophrenia; it is characterised by having delusions ( an unrealistic belief) of persecution, reference, control. These delusions are usually well connected and also have no disturbance of speech and motor behaviour.
A catatonic episode is characterised by a marked disturbance of motor behaviour.
Organic delirium is characterised by clouding of consciousness and disorientation.
An increase in weight, bradycardia, obesity, constipation are signs indicating hypothyroidism. Note that the absence of abdominal striaes rules out the option of cushing’s disease (hypercorticoidism). The increased TSH levels implies an activation of the feedback mechanism signalling the body to produce more thyroid hormones; T3 and T4.
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 (heathroses), 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.).
If you are with someone having a tonic-clonic seizure (where the body stiffens, followed by general muscle jerking), try to:
Stay calm and remain with the person.
If they have food or fluid in their mouth, roll them onto their side immediately.
Keep them safe and protect them from injury.
Place something soft under their head and loosen any tight clothing.
Reassure the person until they recover.
Time the seizure, if you can.
Gently roll the person onto their side after the jerking stops.
Do not put anything into their mouth or restrain or move the person, unless they are in danger. The major step is to ensure the airway is clear, to keep them breathing until the seizure stops.
It is stated that there is a 3rd degree hydronephrotic change in the left kidney; Hydronephrosis is swelling of one or both kidneys (dilation of the renal pelvis and calyces). Kidney swelling happens when urine can't drain from a kidney and builds up in the kidney as a result. There are three degrees of Hydronephrosis:
1st degree (mild)- moderate renal pelvis dilation with few calyces
2nd degree (moderate)- full renal pelvis dilation involving all calyces
3rd degree (severe)- includes the above signs coupled with thinning of the parenchyma. In severe hydronephrosis, surgery is recommended.
Heartburn, gaseous and sour eructation, burning constricting pain behind the sternum and along the esophagus are signs of a reflux disease, these symptoms are observed due to the backflow of gastric acidic content into the esophagus. One main reason is the inefficient constriction/closing of the lower esophageal sphincter or an overproduction of gastric acid. Note that the patient takes Amagel, an antacid which helps in neutralizing the acidic content.
ulcers occur when the acid in the digestive tract eats away at the lining of the stomach or small intestine, creating irritated or raw spots that can become painful open, bleeding sores. Some of the symptoms of peptic ulcer disease include burning stomach pain, feeling full quickly, bloating, intolerance to fatty foods, heartburn, and nausea.
An obstetrical paralysis is a form of paralysis that occurs during birth due to an injury to the nerves of the brachial plexus. Observe that the proximal parts of the baby’s arm are with no defect and this pathology affects the distal arm ‘The hand is flattened, atrophied, cold to touch, hangs passively. Grasping and Babkin’s reflexes are absent at the affected side’. This indicates an obstetrical paralysis affecting the distal area of the arm.
Proximal type will affect the proximal muscles of the arm while the complete form will affect all muscles innervated by the brachial plexus.
Schizophrenia is a mental disorder characterised by disturbances in thought and verbal behaviour,perception, motor behaviour and relationship to the external world. The different clinical types include; Paranoid, disorganised/ hebephrenic, Catatonic, residual or latent, undifferentiated schizophrenia. Catatonic schizophrenia is further divided into an excited form and stuporous form. The patient above is said to have a catatonic stupor; this state is characterised by inability to speak, rigidity, maintenance of weird postures; maintained for a long period of time metc. Snout reflex involves puckering or protrusion of the lips with percussion.
In depressive stupor, the patient will mostly be in a sleepy state, motionless, quiet and have no appetite.
Acute liver failure is a state of hepatic cells dysfunction, caused by unknown earlier liver disease, resulting in general intoxication, coagulation violations, neurological and mental disorders. Its etiology is usually connected with: viral hepatitis (hepatitis B virus, hepatitis A virus), poisonings (mushrooms, dichloroethane, phosphorus, carbon tetrachloride, arsenic), eclampsia, burn disease, anaesthetic gas, antibiotics, sulfanilamides, massive bacterial pneumonia, cirrhosis, hepatic tumours and metastasis.
Advanced liver failure manifests as coma due to the effects of accumulated metabolites on the brain. The patient in question presents with viral hepatitis B ( the probable cause of the liver failure) and a list of other symptoms which indicate neurological and intoxication disorder.
We can pick out: Extended heart borders, low b.p and an increased pulse . These three signs are known as Beck’s triad. They indicate a Cardiac Tamponade ( the impaired pumping ability of the heart due to accumulation of fluid in the pericardium). Note that percussion reveals heart border extension in both directions. The most suitable approach should be a pericardial puncture ( pericardiocentesis) to remove the fluid in the pericardium.
A thoracotomy can be carried out to gain access to the pleural cavity.
Realize that the patient experiences about 10-12 extrasystoles per minute, irregular sinus rhythm with a heart rate of 95bpm, frequent polytopic ventricular extrasystoles. Amiodarone is a class III antiarrhythmic drug; a potassium blocker. It prolongs phase 3 of the cardiac action potential (in this phase, calcium permeability is decreased while potassium permeability is increased- it is also known as the repolarization phase). This drug is indicated in Supraventricular tachycardia, ventricular tachycardia, atrial fibrillation etc.
N/B If phase 3 is prolonged, the heart rate slows down.
Lidocaine,mexiletine, novocaine and quinidine are all class I drugs ( sodium channel blockers) They basically affect conduction ( QRS complex) and have little or no effect on sinus rhythm.
Notice that from the blood analysis, Macrocytes are present- these refer to irregular large Rbcs. 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 deficiency or medications such as antiretroviral drugs. Symptoms include loss of appetite, brittle nails , pale skin, fatigue etc.
Ascorbic acid or vitamin C deficiency will lead to scurvy, petechial bleeding or bruises are common in this case.
Ortner’s sign- tenderness on light percussion on right costal margin by the edge of the palm
Murphy’s sign- a delay of breathing during palpation of gallbladder on inspiration
Kehr’s point- acute pain at the tip of the shoulder
Coupled with the positive result and the above stated signs, the patient also experienced bile vomiting, sharp bitter taste in her mouth, jaundice etc. These are signs specific for pathologies relating to either the gallbladder or liver.Therefore to confirm, the individual should undergo an ultrasound.
A fibrogastrodudenoscopy will be the preferred choice of diagnostic method if it was a Gastrointestinal tract related issue.
Disseminated lung tuberculosis is a clinical form of tuberculosis that arises as a result of lympho-haematogenous spreading of infection and is characterized by bilateral, symmetric nidal injury with predominant localization in upper, subcortical lung sections.
Observe that on X-ray examination of both lungs there presented numerous small low intensity foci, 2-3 mm in size, located in a row along the blood vessels.
Note that hepatocellular carcinoma is the most common primary liver cancer. It usually occurs in patients with liver cirrhosis problems usually caused by hepatitis B or C. Alpha fetoprotein is a tumor marker; it’s elevation indicates tumors such as: Hepatocellular carcinoma, Metastatic disease affecting the liver, Nonseminomatous germ cell tumors, Yolk sac tumor. In pregnant women, it also helps in diagnosing abnormal development such as aneuploidy, neural tube defects etc.
Hepatocellular insufficiency is also termed acute liver failure. In this pathology, lots of metabolites are accumulated in the body ( due to liver's failure in neutralizing them). A key finding can be hepatic encephalopathy ( caused by the toxic effect of such metabolites eg. ammonia on the brain).
BP reading of 140/90 mm Hg twice, 4-6 hr apart
Proteinuria of 0.3 g/L in a 24 hr specimen or >0.1 g/L in a random day-time specimen on two or more occasions 6 hr apart
Dependent edema, some puffiness of eyes, face, fingers; pulmonary edema absent
Output matching intake, ≥30 ml/hr or <650 ml/24 hr
Rise to >160/110 mm Hg on two separate occasions 4-6 hr apart with pregnant woman on bed rest
Proteinuria of >0.5 g/L in 24 hr
Generalized edema, noticeable puffiness; eyes, face, fingers; pulmonary edema possibly present
<20 ml/hr or <400 ml to 500 ml/24 hr
Polycystic ovarian syndrome is a disorder found in women of reproductive age commonly due to hormonal disorder (high level of androgens). This disorder is characterised by infrequent menstrual cycle, pelvic pain, weight gain etc. The ovaries mostly develop follicles (collection of fluids). Realise that the patient is of a reproductive age and experiences infrequent menstruation; the result of ultrasound, confirms the polycystic ovary pathology.
Algodysmennhorhea is characterised by painful menstruation or menstrual cramps during menstruation.
Premenstrual syndrome is a group of symptoms females usually experience a week or two before menstruation.
Lordosis, kyphosis, and scoliosis refer to curvatures of the spine. Lordosis refers to the excessive inward curvatures of the spine at the cervical and lumbar regions, while kyphosis refers to the excessive outward curvature of the spine specifically at the thoracic region. Scoliosis refers to the abnormal sideways curves of the spine.
Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection.
It can be clinically assessed when there is Fever (>38*C); Respiratory rate >22cpm; Tachycardia >100bpm; Systolic BP <100mmHg; altered consciousness.
Sepsis is a common complication when there is overwhelming infection. In this case, it is a complication of burns injury (presents 20th day after the trauma).
Notice that the woman in question gave birth about a year ago and experienced a severe blood loss during delivery; this is the leading cause of sheehan’s syndrome. Sheehan’s syndrome is one of the major causes of hypopituitarism in females; it is due to pituitary infarction as a result of postpartum hemorrhage. fatigability, significant weight loss, weakness, and loss of appetite all include associated symptoms.
The meat is infected by Trichinella and should be properly disposed. consumption of this meat will lead to trichinosis.
A person with insufficient iron in the blood will experience symptoms such as; fatigue, headaches, temperature sensitivity, heart palpitations, cold hands and feet, pallor of mucous membrane, cracks on the side of the mouth, inflammation of the tongue, brittle nails etc. These patients also experience an iron deficiency anemia which is characterised by a reduction in hemoglobin level and color index.
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 an as Beri-beri, Vitamin C - Scurvy , Vitamin A - night blindness.
Thoracocentesis is a procedure in which a needle is inserted into the pleural space to remove fluid or air. The Chest X-ray reveals hydropneumothorax on the left with fluid level at the 7th rib; therefore a thoracocentesis should be carried out here to evacuate the air and fluid.
Laparotomy: is a surgical incision of the abdominal cavity performed to examine the abdominal organs and aid diagnosis. Indications include: abdominal hemorrhage or hemoperitoneum, blunt chest trauma, peritonitis, intestinal obstruction etc and is contraindicated in cases of severe sepsis and malignancy.
Laparoscopy: A surgical procedure in which the abdominal organs are observed with the use of a laparoscope (a camera). Unlike a laparotomy, it uses small incisions. It is also known as a keyhole surgery or minimal invasive surgery. Indications include: Cholecystectomy, gastric bypass.
Laparocentesis: is simply the puncture of the peritoneal cavity to obtain its fluid.
Realize that the above patient received a blow to the abdomen with the steering wheel- which indicates a blunt trauma; peritoneal irritation signs are positive- an indication for peritonitis.
A dysfunctional uterine bleeding (DUB) is the bleeding, not associated with organic diseases of women’s genitals, interrupted pregnancy or systemic diseases of the organism.
The dysfunctional uterine bleeding can appear at any age. Depending on the time of their onset, juvenile bleeding (at child age and in period of pubescence), bleeding of reproductive period, climacteric bleeding are classified. DUB are the manifestations of initial stages of neuroendocrinological diseases, especially of blood diseases. Realise that from physical examination the cervix is clean, the uterus is not enlarged and shows no pathologic changes.
The prostate is the largest accessory gland in the male reproductive system.
It secretes proteolytic enzymes into the semen, which act to break down clotting factors in the ejaculate. This allows the semen to remain in a fluid state, moving throughout the female reproductive tract for potential fertilisation.
Anatomically, it is positioned inferiorly to the neck of the bladder and superiorly to the external urethral sphincter. Therefore, an enlarged prostate gland will cause urinary retention and disturb the outflow of urine (weak flow of urine and usually painful).
Prostate cancer is most common in adult males and usually asymptomatic until advanced stage. Patients with prostate cancer commonly presented with symptoms that included urinary complaints or retention, back pain, and hematuria.
The findings on digital rectal examination (DRE) indicates malignancy - enlarged; asymmetrical; central fissure is smoothed out. These points to prostate cancer.
Prostate Specific Antigen (PSA) is a useful tumor maker.
PSA > 10ng/dL is worrisome at any age
Aminolevulinic acid and coproporphyrin are amino acids necessary for the synthesis of Heme. The excretion of these constituents in urine indicates either an inherited or secondary Porphyria. One of the most frequent causes of the secondary form of this disease is Lead poisoning. An increased degradation of porphyrin will lead to a decrease in Hemoglobin synthesis. Also note that the patient experiences Asthenovegetative syndrome ( physical and nervous fatigue), pain in the hepatic area and stomach; these are classical signs of Lead poisoning.
Carbon monoxide poisoning will be characterised by headache, lethargy, dizziness, loss of consciousness etc.
UTERINE INERTIA (“Failure to progress”, hypotonic uterine dysfunction) describes lack of progressive cervical dilatation and/or descent of the fetus. It is such a condition in which uterine contractions strength, duration and frequency are inadequate, that’s why cervical effacement, dilation and fetal descending is slower than in normal labor. Since the baby’s head is already in the pelvic outlet plane and cant proceed further due to inadequate contractions, an outlet forceps is used in assisting delivery.
Labour stimulation will occur in situations such as preeclampsia, eclampsia, diabetes, premature rupture of membranes etc. Cesarean session in cases of breech or fetal distress.
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.
One of the forms of stomach dyskinesia of hypertonic type is pylorospasm. It is observed mainly in babies, especially in the first weeks and months of life. Pylorospasm in children is caused by functional disturbances of the nervous- muscular system of the stomach pyloric part. Pylorospasm is marked by weak development of muscles in cardial part of the stomach and its more expressed development in the area of the pylorus. It promotes development of vomiting and eructation. Symptomatically, the major difference between pylorospasm and pyloric stenosis is the presence of Projectile vomiting in stenosis.
In esophageal achalasia, the lower esophageal sphincter fails to open during swallowing leading to the build up food in the esophagus.
An increased content of Erythrocytes in CSF findings indicates “ intracranial hemorrhage”. Presence of protein and low glucose in CSF are not specific and can indicate pathologies such as an infarct, meningitis, sepsis etc. Hypertonia and depressed consciousness are also general signs and can be found in any of the above pathology.
Renal Cell Carcinoma is most common in men 50-70 years old. It manifests clinically with the classic triad of flank pain, hematuria, and flank mass. There could also be secondary polycythemia; fever and weight loss.
From the question stem:
Supra public area is without alteration and no abnormal findings on cystoscopy (i.e. no problem with the urinary bladder).
External genitalia and prostate - no abnormal findings.
So the best option here associated with hematuria (blood traces in urine) is Renal carcinoma.
The injury from 7 days ago has been infected by clostridium tetani; the causative agent of tetanus. Notice that the patient experiences Trismus (lockjaw) which is a major indication of a tetanus infection.
Clostridium tetani is a gram positive, obligate anaerobic, spore forming bacillus that resembles a tennis racket or drumstick; it is the causative agent of tetanus (lockjaw). This pathology is characterised by the stiffness of muscles (spactic muscle), spasms that last for a few minutes, fever, trouble swallowing, increased blood pressure etc. This bacteria produces a toxin ( a neurotoxin called tetanospasmin) that has a potent effect in the brain leading to the above mentioned stiffness.
Ulnar Nerve: Sensory innervation to the Fifth and medial half of the fourth digits; Motor innervation: flexion, adduction and abduction of 4th and 5th digits. Injury to this nerve causes Claw hand
Median Nerve: innervates the skin of the palmar side of the index finger, thumb, middle finger, and half the ring finger, and the nail bed; motor innervation: flexion of lateral fingers, thumb opposition, lumbricals of index and middle fingers. Injured in Carpal Tunnel syndrome and leads to ape’s hand.
Radial Nerve: Sensory innervation to the dorsum (back) of the hand except the little finger (supplied by ulnar). Motor innervation to the dorsum of the hand. Injury leads to loss of grip strength, wrist drop.
Notice that, there was no pulse detected over the pedal and popliteal arteries. This is a classic sign of ‘atherosclerosis obliterans’ a peripheral artery disease caused by occlusion of a major,medium or small sized artery ( in this case of the lower left extremity).
Obliterating endarteritis is an inflammation that takes place in the inner lining of an artery (intima); it is seen in complications in relation to infections such as tuberculous meningitis, syphilis or in severe radiation poisoning.
Pneumonia is a form of acute respiratory infection that affects the lungs. Pneumonia is caused by a number of infectious agents, including viruses, bacteria and fungi. Often characterized with cough; difficulty in breathing (dyspnea) and fever.
The lungs are made up of small sacs called alveoli, which fill with air when a healthy person breathes. When an individual has pneumonia, the alveoli are filled with pus and fluid, which makes breathing painful and limits oxygen intake.
A healthy lung will produce a tympanic sound on percussion as a result of the air in the alveoli. However, there will be percussion dullness when the alveoli is filled with pus and fluid. Crackles on auscultation of the lung also indicates fluid in the alveoli.
Cystic fibrosis (Mucoviscidosis) is an inherited disorder that results in a buildup of thick and sticky mucus in the lungs, airways, and other organs. Excess mucus in the lungs can lead to coughing, breathing problems, scarring (fibrosis), and an increased risk of lung infections. There is no cure, but treatments can improve both the length and quality of life for people with the disease.
Cystic fibrosis is caused by mutations in the gene that encodes the cystic fibrosis transmembrane conductance regulator (CFTR). This protein functions as a channel across the membrane of cells that produce mucus, sweat, saliva, tears, and digestive enzymes.
From the history, the mother already had a child that died of a pulmonary pathology (inherited disorder) and the recurrent infections (bronchitis) all points to Cystic Fibrosis.
All other options given are not hereditary.
Amyloidosis refers to a number of protein deposition diseases in which normal or variant forms of proteins aggregate and form insoluble ﬁbrils.The most common clinical manifestations of amyloidosis is nephrotic syndrome with or without renal impairment, heart failure, sensomotor and / or peripheral neuropathy and hepatomegaly. The special features of renal amyloidosis include rare hematuria and leukocyturia. Notice that the patient experiences proteinuria, hematuria and leukocyturia on the background of rheumatoid arthritis which are signs of a secondary renal amyloidosis ( specifically known as a Reactive Amyloid A Amyloidosis).
Note that the patient has no history of allergy, no infection or strenuous activity were mentioned; these rule out the options of atopic, infectious allergic and exercise induced asthma respectively. Aspirin induced asthma presents with three Keys; An Asthmatic reaction, intake of aspirin or a NSAIDs and presence of nasal polyps (all of which are present in the above case). The disorder is thought to be caused by an anomaly in the arachidonic acid metabolizing cascade. When medications such as NSAIDs or aspirin block the COX-1 enzyme, production of thromboxane and some anti-inflammatory prostaglandins is decreased, and in patients with aspirin-induced asthma, this results in the overproduction of pro-inflammatory leukotrienes ( especially cysteinyl leukotrienes), which can cause severe exacerbations of asthma and allergy-like symptoms.
The question stem clearly states that the patient has been diagnosed with Rheumatoid Arthritis.
So basically, we need to differentiate Rheumatoid Arthritis and Osteoarthritis so that we can arrive at the correct answer specific for Rheumatoid Arthritis.
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.
So let’s answer the question:
From the question stem - Radiocarpal (wrist joints); metacarpophalangeal joints were affected with morning stiffness lasting >1.5hrs
These are clearly signs and symptoms of Rheumatoid Arthritis...
From the options it is clear that the only option talking about RA is joint space narrowing; usuration
The other options are talking about Osteoarthritis.
Since the patient complains about spontaneous bruises, bleeding gums, numerous hemorrhages of various time of origin, the blood platelet level should be checked. Platelets/ thrombocytes help in blood clot formation.
The above patient is experiencing Postoperative nausea and vomiting; since she is already on prednisolone medication, an increased dose of this drug would be the best possible means of prevention. Note that prednisolone is a glucocorticoid and has immunosuppressive,antipyretic and antiinflammatory effects; it also possesses a direct antiemetic ( stops vomiting ) effect.
Trigeminal Neuralgia is a condition which produces repetitive,unilateral, shooting/shot-like pain in the areas innervated by the trigeminal nerve ( the face). It is triggered by chewing, talking or touching certain parts of the face. Typically lasts for seconds to minutes but episodes often increase in intensity and frequency over time.
Recall that the trigeminal nerve, CV is a mixed type of nerve, has 3 major branches;
V1 (ophthalmic), V2( Maxillar), V3(mandibular). This nerve is responsible for mastication, facial sensation, somatosensation from anterior ⅔ of the tongue, and innervates the tensor tympani.
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
idiopathic thrombocytopenic purpura is also known as Immune thrombocytopenic purpura.It 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). The patient in review presents with thrombocytopenia ( low platelet levels );- 20 x 10^9/L ( norm = 150 − 400 · 10^9/L ) and also bleeding gums.
Osler weber syndrome is a genetic condition characterized by abnormal vessel formation in the skin and mucous membrane of organs eg lungs, brain etc
disseminated coagulation syndrome presents with; widespread clotting factor activation, deficiencies in clotting factors leading to bleeding state.
Homans’ sign test is a physical examination procedure which appears positive in cases of Deep vein Thrombosis (DVT). It is also referred to as the dorsiflexion sign test.
Rovsing’s sign indicates appendicitis; a positive sign is observed when pain is felt in the right lower quadrant during palpation of the left lower quadrant.
Courvoisier’s sign is seen in an enlarged palpable gallbladder.
Mayo-Robson’s sign is an indicator for pancreatitis.
Amongst the listed radioactive substances, an exposure to radioactive iodine will result in the irritation of the nasopharynx, increased tear production, swelling of the neck, loss or a change in taste etc. Note that radioactive iodine is mostly used in the treatment of thyroid cancers and is readily absorbed by the thyroid gland. Majority of the other listed radioactive substances will lead to acute radiation sickness, skin burns etc.
When CO gets into the body, it attaches to hemoglobin ( responsible for oxygen transport) since it possesses higher affinity to Hb than Oxygen. This leads to the formation of carboxyhemoglobin. To estimate the severity of this state, the blood carboxyhemoglobin level should be checked. In non smokers, the carboxyhemoglobin level is normally 2-3% and 7-9% for smokers.
Acute hematogenous osteomyelitis is an infection of the bone usually caused by a bacteria and common in children less than 5 years; typically affects the metaphysis of long tubular bones. Children present with fever, localized pain, swelling, and rarely erythema around a long bone, limited range of motion, and limping or refusal to bear weight or use an extremity (pseudoparalysis).
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.
Realise that the patient is in a state of hypertensive crisis (BP- 225/115 mm Hg). For emergency remedy, the patient should be administered Labetalol, Torasemide, magnesium sulfate ( in their right doses) in combination with fluid therapy.
Abortion refers to the termination of a pregnancy before 22 weeks of gestation or before 500 grams of fetal weight. Early arbortion occurs before 12 weeks of gestation while late abortion takes place between 12-22 weeks. The above patient experiences an increased uterine tone, pain, bleeding, shortened cervix all of which are indicating a risk of abortion accompanied with hemmorhage. An incomplete abortion is observed when there is retention of some of the products of conception in the uterus eg. the placenta.
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.
Lung abscess can be defined as necrosis of the pulmonary tissue and formation of cavities containing necrotic debris or fluid caused by a microbial infection.
It is commonly characterized by a productive cough; chest pain; dyspnea.
On examination - One can perceive a foul-smell from the mouth when the patient coughs. The amount of sputum as a result of the productive cough is small initially, with a rusty tone (rusty as a result of RBCs that are broken down).
If not properly treated, the abscess progresses by draining the destructive cavities through the bronchus with the daily quantity of the sputum increasing and even reaching 500 ml and more. At this time it is possible for the sputum to be associated with hemoptysis (coughing up of blood).
Acute abscesses are less than 4-6 weeks old, whereas chronic abscesses are of longer duration.
Due to the presence of the tumour, the pressure over the abdominal aorta is increased leading to the bulging out or ballooning of the affected part of the aorta; this theory is further proved by the presence of a systolic murmur over the affected region indicating an aneurysm of the abdominal aorta.
This pattern of fever is specific for malaria. The symptom stated above refers to ‘Paroxysm’ ( a cyclical occurrence of sudden coldness followed by shivering and then fever and sweating, occurring every two days (tertian fever) in P. vivax and P. ovale infections, and every three days (quartan fever) for P. malariae. P. falciparum infection can cause recurrent fever every 36–48 hours. For diagnosis, microscopy of blood smear and thick blood film is used (to detect plasmodium).
The patient being a drug addict raises strong suspicion for the HIV infection. The presence of poly lymphadenopathy, herpetic rashes in the oral cavity; on abdominal palpation: the liver and spleen are enlarged are all signs indicating an HIV infection.
Herpetic stomatitis is seen in individuals with herpes infection (oral herpes) and poly lymphadenopathy are not usually seen.
Pneumonia is an infection of the lungs ( viral, bacterial or fungal) characterised by the presence of fluid filled air sacs or alveoli. From the analysis, the increased leukocyte number indicates a bacterial infection and the result from auscultation shows the lungs are affected. The results from the x-ray confirms the presence of an abscess (a pus filled cavity) which causes the foul smelling sputum. Lung abscesses are one of the various complications of pneumonia; others include; bacteremia, septic shock. Pleural effusion etc.
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. Note that the patient in view has reduced visual acuity in both eyes and has a net like vision ( cloudy); these signs indicate presence of cataract.
In conjunctivitis, we see red eyes ( inflammation of the transparent membrane- conjunctiva), it doesn't affect visual acuity.
Norms; gestation period- 280 days or 40 weeks up to 42 weeks
birth weight- 3-3.5kg ( 3000-3500g)
Body length- 45-55cm
The baby in question underwent a full term gestation period (41 weeks) but is underweight ( 2400g). This underweight is due to complications that occurred during gestation as stated “The pregnancy was complicated with severe gestosis in the second semester”. We can therefore conclude that the baby who had a full term gestation had some intrauterine growth restrictions.
A premature infant is one which is born before 37 weeks of gestation.
A post mature infant is one born after 42 weeks of gestation
Tuberculosis is a disease caused by an acid fast bacteria, Mycobacterium tuberculosis. Streptomycin, Rifampicin, Isoniazid, pyrazinamide and ethambutol are very active drugs chosen for its treatment. The following are lists of side effects associated with these drugs:
Streptomycin- vestibular and auditory ( ototoxicity) dysfunction, non oliguric renal failure
Rifampicin- red/ orange discoloration of body fluids e.g. tears, urine; flu-like symptoms, hepatitis, diarrhea, thrombocytopenia.
Isoniazid- hepatitis, peripheral neuropathies
Pyrazinamide- asymptomatic hyperuricemia, joint pain, rash
Ethambutol- retrobulbar optic neuritis
Dental caries is an infectious disease caused by the complex interaction of caries-causing bacteria ( eg. streptococci mutans) with carbohydrates (i.e., sugars) on the tooth surface over time. Cariogenic bacteria metabolize carbohydrates for energy and produce organic acids as byproducts which reduce oral pH leading to demineralization of the teeth. One of the most effective methods to prevent caries is by promoting remineralization and slowing down demineralization. This can be accomplished with fluoride therapy. It is widely accepted that the regular use of fluoride, such as in drinking water, is extremely effective at preventing dental caries. The fluorine content in the community’s water supply is 0.1 mg/L which is low ( norm >0.5 mg/L). Water fluorination should be used to prevent dental caries.
rule of “nines” – area of different areas of the body is proportional: anterior surface of the trunk – 18 %, posterior – 18 %, lower limb – 18 %, external genitals – 1 %)
" rule of “palm”. It is used if burns are limited and located on different areas of the body. According to the rule of palm takes 1 % of the skin surface.
Division of the burns on superficial (I, II, III A st.) and deep (III B-IV st.)
I stage – hyperemia of the skin
II stage – separation of epidermis with formation of bullas
III A stage – necrosis of superficial layers of the skin with saving of bulbs hair, sweat glands and sebaceous glands.
III B stage – necrosis of all the derma
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.
No signs of focal myocardial injury on ECG rules out the option of acute cardiac infarction. Angina pectoris is a clinical syndrome due to myocardial ischemia characterised by episodes of precordial ( area behind the sternum, above the heart) discomfort or pressure, typically triggered by stress and relieved by rest or sublingual nitroglycerin. 3 forms are present, they include;
Stable: pain follows a steady pattern, triggered by stress.
Unstable/Progressive: occurs at rest or during minimal exertion, follows a crescendo pattern ( prolonged, more severe and frequent), usually requires an increase in nitroglycerin dose as it progresses.
Variant/prinzmetal: occurs at rest usually between midnights and early morning.
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, Gotron 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.
The patient presents with possible signs of an infection; fever, tachycardia and worsening of the wound. The physical appearance of the wound indicates an infection most like an anaerobic bacteria eg clostridium.
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. Remember from the question stem, the patient attended a 5-day long celebration; most likely he has been stressed within these days and stayed without alcohol consumption leading to delirium tremens. Senile psychosis is brain degenration due to old age.
Etiology: Group A Beta hemolytic Streptococci (Streptococcus pyogenes)
This commonly presents as Pharyngitis - upper respiratory tract infection (URTI) accompanied with fever.
The common complications are myocarditis and post Streptococcal glomerulonephritis. However, these symptoms only present about 1-5 weeks (average of 20 days which is 2-3 weeks) after a Group A Streptococcal infection.
Note, the question stem says the 8 year old developed fever, suffocation and heart pain 2 days after an URTI. These are symptoms of Myocarditis but it is non-rheumatic because they developed 2 days after an URTI and not up to 2-3weeks.
Diagnosis is based on Jones Criteria:
Joint (migratory arthritis)
Nodules in skin (subcutaneous)
Mediated by Type II hypersensitivity reaction and ASSOCIATED WITH ASCHOFF BODIES AND ANTISCHKOW CELLS; increased anti-streptolysin O titers.
An ectopic pregnancy occurs when implantation takes place outside the walls of the uterus; in most cases it occurs in the fallopian tubes ( tubal pregnancy). The patient presents with a history of missed periods for about 2 months ( an early sign of pregnancy). Typical signs include pelvic and severe lower abdominal pain, mass present in the uterine appendage ( adnexa). Notice that on examination, the patient presents with enlarged and very painful uterine appendages on the right side which confirms a right-sided tubal pregnancy. Right ovary apoplexy refers to the rupture of the ovary, it presents with severe pain, bleeding into the abdominal cavity and signs of irritation of the peritoneum.