Cases

WIKIPEDIA CASES SENARIO
- 1 - DR N.GWELY

CASE 1 :
A Iemale patient 46 years old, non smoker goes to her GP because she has
become increasingly overweight. She has gained 9 Kg in weight over the past
6 months. She also noticed that she was bruising easily. She Iound diIIiculty to
get up Irom her chair or to climb stairs. She Ielt depressed and Iound her selI
waking early in the mornings. She had no previous physical or psychiatric
illnesses.
On examination :
She is overweight particularly in the abdominal region .
Skin bruises.
Grade 3 motor power in shoulder abduction & hip flexion.
Peripheral oedema
Hyperpigmented skin patches.

ENDOCRINOLOGY CASES
1. What is your likely diagnosis??
2. How can you confirm your diagnosis by investigations ??
3. What is the cause of peripheral oedema ??
4. When can this oedema disappear without treatment ??
5. How can the heart be jeopardized in this disease ??

- 2 - DR N.GWELY
CASE 2:
A Iemale patient 17 years old was discovered to be diabetic on
presenting to the outpatient clinic suIIering Irom general ill health and
weakness.

The patient received her ttt regularly & was properly controlled Ior nearly
5 months. Then she started to suIIer Irom repeated acute attacks oI
hypoglycemia. Her doctors realized that the dose oI insulin she was
receiving was big & so they reduced it.

The patient used to visit the clinic regularly Ior Iollow up & her blood sugar
was controlled on insulin & diet treatment. During one oI her visits, the doctor
noticed yellow discolouration oI her skin. Some routine investigations were
asked in the Iorm oI: liver Iunctions, renal Iunctions, blood sugar, uric acid &
blood Holds.

1. What types of DM may this young lady have ?
2. Mention the mechanisms underlying the more common type ?
3. What are the acute Conditions that can complicate this type ?
1. What is the reaction of the body to the occurrence of hypoglycemia ??
2. How do you explain the occurrence of this hypoglycemia in the case ?
1. Mention one important question you would ask her in the history?
2. Explain the yellowish discolouration of the skin.
3. Mention other causes of this findings
4. What is the most common type of dyslipidemia in diabetic patients ?

- 3 - DR N.GWELY
CASE 3:

A male patient 28 years old was diagnosed as having pulmonary TB in a TB
sanatorium. He was given his medication & advised to come to the clinic every
month Ior Iollow up investigations & to receive his monthly ttt. The patient
received his treatment Ior only 3 months & then he neglected everything. So he
came back 4 months later with marked weakness, Iatigue and marked loss oI
weight. He also complained oI persistent diarrhea during the last 4 months
together with occasional abdominal colics & polyuria.
On examination:
Pallor.
Hyperpigmentation especially noted in some areas oI his body.

1. What is your possible diagnosis ??
2. How would you confirm your diagnosis by investigations ??
3. What caused the problem ?
4. What is the most common cause of this disease
5. Enumerate other endocrinal causes of chronic diarrhea(bn (#
6. Mention an important point in general examination in this patient.
7. Explain the following features in the patient:
a. Abdominal colics.
b. Marked weakness, Iatigue & marked loss oI weight,
c. Polyuria.
d. Pallor.
8. In which special areas was the hyperpigmentation found ? What
caused it ?
9. How would you treat this patient ??

- 4 - DR N.GWELY
CASE 4:
A Iemale patient 27 years old came presented to the ER with DCL severe
vomiting & abdominal pain. Her relatives said that she has been suIIering
Irom polyuria since Iew months, She was getting up to pass urine 5 times a
night. About 1 week ago, she developed abrupt onset oI sever thirst and
polyuria They also stated that she had bony pain &backache and persistent
constipation.
On examination:
BP: 110/80.
Pulse: 50 / min, extrasystoles.
Temp.: 37 C.
RR: 19/min.
Skin: dry inelatsic skin with scratch marks.
Decreased JVP.
Investigations revealed;
Plain UT: renal stones.

The patient was managed Irom this problem, and was advised as regards her
deIinitive treatment, BUT: she reIused & went home. Two years later she
came back with general ill health, conIusion, vomiting, pericarditis, earthy
look and ammoniacal mouth odour

1. What are the most likely diagnoses arranged in order ?
2. Explain the presence of polyuria in either cases ?
3. Explain the presence of renal stones in either cases.
4. Name another disease with the combination: itching + bradycardia
5. Comment on the BP.
1. What is your diagnosis ??
2. What do you expect to find the serum potassium ??

- 5 - DR N.GWELY

CASE 5:
A 60 years old male, obese, heavy smoker who has been on insulin and
metIormin Ior 12 years presents with: breathlessness, sweating, vomiting and
acute abdominal pain. He also suIIered Irom a severe attack oI acute chest
pain: diIIuse retrosternal radiating to the leIt arm that lasted Ior one hour &
was partially relieved by drug His blood sugar was markedly elevated:
550mg/dL.
On examination:
BP: 100/60.
Pulse: 130/min, weak,
Temp.: 37.7 C.
RR: 34 / min (deep respiration).

The patient's overall management was started.

The patient stayed in hospital thereaIter Ior 2 more weeks during which his
overall condition stabilized & his blood sugar was perIectly controlled. He
was discharged & put on a total daily dose oI 60 units oI insulin mixtard to be
administered in 2 divided doses (morning & evening).

1. What is the probable diagnosis of the patient's condition ?
2. Mention 3 most important investigations ?
3. Mention 3 possible explanations for the acute abdominal pain.
1. What are the types of fluids required to this patient ?
2. How would you adminster insulin after control of the acute
condition ??
1. Calculate the proper morning & evening doses.'
2. What are the advantages of human insulin & insulin pump ??

- 6 - DR N.GWELY

CASE 6
A 53 years old obese man, hypertensive on amlodipine 5 mg / day presented
to the outpatient clinic Ior Iollow up oI his blood pressure.
On examination:
BP: 150/100.
BMI: 36Kg/m
2
.
Chest, heart, abdominal & neurological examination were Iree.
LLs: mild oedema.
Investigations revealed:
FBS: 119mg/dL.
2hpp: 177mg/dL.
Hypercholesterolemia, Hyper triglyceridemia.
Normal liver and kidney Iunctions.
Urine analysis: normal.

2. How can you explain the oedema in this patient ??
3. Suggest a suitable drug to control the patient's BP ??

- 7 - DR N.GWELY

- Insulin stimulates glycogenesis & gluconeogenesis.
- DKA may be occur during the use of insulin pump.
- Absence of glycosuria excludes diabetes.
- Rosiglitazone is a benzoic acid derivative that increases insulin secretion.
- DKA may be the first presentation of diabetes.
- Diabetes may occur due to liver failure, renal failure & adrenal failure
- C - peptide is an important investigation for monitoring of diabetes.
- Sulphonylurea therapy in diabetes decreases the number of peripheral
insulin receptors.

- In the management of newly-diagnosed 30-year-old diabetes, insulin
requirements during the first 8 weeks often decrease.

- Polyphagia occurs in diabetes due to glucose uptake in the cells of the
satiety centre of the hypothalamus.

- Monozygotic twins show approximately 100 % concordance for NIDDM.
- Hypercholesterolemia is a finding in hypothyroidism.
- Chlorpropamide is oral hypoglycemic drug that stimulates insulin secretion.
- Hypoglycemia may occur due to hypopituitarism or hypothyroidism.
- Obesity may occur due to hypercorticism or hypothyroidism.
- Hba1c is a sensitive screening test in diabetes.
- Honeymoon phase is associated with temporary 8 cell improvement in type
2 diabetes.

- ARBs represent a good choice in treating diabetic nephropathy.
- In diabetes during pregnancy, the baby is usually smaller than expected
from gestational age.

- ACE - Is represent the antihypertensive therapy of first choice for the ttt of
type 1 diabetes.

- Repaglinide is a PPAR agonist that decreases insulin resistance.
- Increased serum prolactin concentration occurs in hypothyroidism.

- 8 - DR N.GWELY
- Missed meal is a very important cause of hypoglycemic coma.
- Hyperkalemia is a typical finding during the ttt of DKA.
- In diabetes, glycosuria is usually due to reduced renal threshold.
- In type II diabetes, there is a clear evidence of autoimmunity.
- Obesity predisposes to NIDDM in genetically susceptible individuals.
- Insulin requirements usually decrease throughout pregnancy.
- Hypoglycemia is associated with tremors , palpitation & dizziness.
- In diabetes, carbohydrate intake should be 50 % of the total caloric intake.
- Mild diabetes during pregnancy responds well to sulphonylurea & diet
therapy.

- Severe hypoglycemia occurs in chronic & not in acute liver cell failure.
- In myxoedema, low serum free T3 precedes an in serum TSH
concentration.

- Sulphonylurea therapy in diabetes causes more weight gain when given
with biguanide therapy.

- In the management of newly-diagnosed diabetes, Hba1c should be
monitored weekly.

- In the management of DKA, glucose should be avoided unless
hypoglycemia occurs.

- In diabetes, neuropathy may present with sudden deaths
- In diabetes, microalbuminuria suggests renal tabular dysfunction.
- AMI & stroke are recognised precipitating factors for DKA, hyperosmolar
non-ketotic coma and hypoglycemic coma.

- Lactic acidosis may occur due to toxicity of biguanides & morprlineT
- Tetany occurs due to alkalosis, hypocalcemia &^hypokalemia
- Polyuria is a recognised manifestation of Addison's disease & Cushing's
syndrome.

- Sudden ^withdrawal of corticosteroids may result in an emergency.
- Glucose toxicity occurs in type 1 diabetes.
- MODY represents a genetic defect resulting in insulin resistance.

- 9 - DR N.GWELY

CASE 1:
A 15 years old male patient presented to the hospital because he Ielt unwell
and Ieverish since one week.
On examination:
Liver: shrunken liver, with sharp edge.
Spleen: enlarged.
Initial Investigations revealed:
Serum bilirubin: 1.5 mg / dl.
AST, ALT: moderately elevated.
CBC: . anemia with reticulocytosis.

CASE 2
A Iemale patient 38 years old with a long history oI CCPs presented to the
hospital with conIusion, apathy, irritability, jaundice and Ilapping tremors.
She had been completely normal one week ago.

GIT CASES
1. What are the 2 most likely possibilities ?'
2. How can you explain the fever ?
3. How would you investigate this patient to reach proper diagnosis ??
4. Enumerate the causes of shrunken liver ?
2. What are the different causes of this fatal condition?
3. What are the causes of death in this condition ??
4. How would you find the following in the investigations:
Plasma glucose.
Serum albumin.
Serum transaminases.
INR.

- 10 - DR N.GWELY
CASE 3:

A Iemale patient 40 years old presented to the hospital witty increasing Iatigue
and general ill health during the last year. She also complained oI dull aching
pain in her right hypochondrium since 6 months. The patient gave no history
oI previous blood transIusion or exposure to contaminated syringes.
On examination:
Eyes: no jaundice.,
Abdomen: hepatosplenomegaly.
There were no maniIestations oI liver cell Iailure.
Initial Investigations revealed:
Serum bilirubin: 2 mg / dL.
AST: moderately elevated.
ALT: moderately elevated.
ALP: moderately elevated
Serum albumin: 2.8gm/dl

The patient was admitted to hospital Ior management.
Further Investigations revealed:
CBC: anemia.
Abdominal ultrasonography: Splenomegaly bright hepatomegaly.

1. What is your initial DD ??
2. Why couldn't you detect jaundice in the eyes of this patient ??
3. What is the type of the hyperbilirubinemia in this patient ??
4. How do you expect to find the urobilinogen in urine ??
5. Which of the abovementioned enzyme is most reliable in this setting
?? Why ??
6. What causes marked elevation of the abovementioned enzymes ??
7. Name 2 most important investigations that could help you detect
the disease ?

- 11 - DR N.GWELY

1. What are the 2 most important investigations you would ask at this
point ??
2. What is your overall DD at this point ?
3. What are the possible causes of the patient's anemia ??
4. What are the causes of bright hepatomegaly on ultrasonography ??
5. Describe the pathology of the patient's liver in this case.
6. How do you expect to find the PT in this patient ??
7. How would you treat this patient ??

- 12 - DR N.GWELY
CASE 4:
A male patient 46 years old with a past history oI Bilharziasis had been losing
weight during the last year together with increasing maniIestations oI weakness
and general ill health. He presented to the hospital with jaundice and dark
coloured urine dating since 4 months. He said that he consulted a GP in his
village who prescribed him some medication
On examination:
Eyes: jaundice.
Nails : clubbing.
LLs: oedema oI both LLs.
Skin: palmar erythema & echymotic skin patches.
Trunk: gynecomastia.
Abdomen: shrunken liver, splenomegaly & ascites.

The patient was admitted to hospital Ior management during which he
developed acute Iever, abdominal pain Iollowed by deterioration in his
consciousness level.

Generalized abdominal tenderness.
Flapping tremors.
2. How would you confirm your diagnosis ??
3. How would you treat this condition ??
2. How would you investigate this patient to reach your proper
diagnosis ??
3. What is the pathological role played by Bilharziasis in this patient ??
4. What is the clinical stage of this disease ??
5. What is the most common skin manifestation in this condition ?
6. Explain the echymotic skin patches , How would you treat them ?
7. Discuss the pathogenesis of ascites in this patient. ,
8. What do you expect to find on examination of the patient's mouth.
9. Mention how can the odour of the mouth help you in diagnosis of
diseases ?
10. Mention 2 possible causes of gynecomastia in this patient.
11. Explain the occurrence of clubbing in-this case ?

- 13 - DR N.GWELY
CASE 5:
A Iemale patient 44 years old presented with a(5jnonths history oI diarrhea
associated with loss oI weight1& Irequent abdominal pain. She also suIIered
Irom night sweats, night Iever, numbness & tingling m her hands & Ieet.
On examination:
- Pallor.
- Pulse: 100 / min, with multiple extrasystoles.
- Tenderness & mass in the right iliac Iossa.

Miscellaneous questions (enumerations).
Discuss the importance oI corticosteroids in liver & GIT diseases.
Enumerate the causes oI mixed jaundice.
What are the markers oI chronicity in HBV ?
Clinical - chemical diagnosis in hepatobiliary diseases (Liver screening)
What is the most important laboratory parameter oI hepatocellular integrity ?
What is the most important laboratory parameter oI biliary integrity ?
What is the most important laboratory parameter opiepatocellular synthesis ??
How would you screen cirrhotic patients Ior early detection oI HCC?
What are the important tumour markers in GIT diseases ??
What are the important auto antibodies in GIT diseases ??
Enumerate causes oI non obstructive cholestasis.
Enumerate the causes oI chronic diarrhea with abnormal Iindings on endoscopy.
Enumerate the causes oI chronic diarrhea with normal Iindings on endoscopy.

1. What is your clinical diagnosis ??
2. What are the 2 most likely etiological diagnoses arranged in order ??
3. Mention one point you would like to examine in the patient.
4. How can you differentiate between them by one investigation
5. What are the complications of the most probable etiology ?
6. Explain the numbness & tingling in this patient.
7. What could cause pallor to this patient ??
8. What are the laboratory tests you would like to request..??
9. What are the drugs that can. cause chronic diarrhea ?

- 14 - DR N.GWELY

QUESTION 1
A 55 year old male:
Symptoms oI dyspnea on exertion, easy Iatigability, and lassitude Ior
past 2 to 3 months.
He denied hemoptysis, GI, or other bleeding.
He claimed diet was good, but appetite varied.
- Hb: 7 gm
- MCV: 73 FI.
- Serum iron:
Mention the initial investigation you would request.
QUESTION 2
A 57 year old male:
Seen by local physician Ior routine preoperative exam, prior to dental
surgery.
Found to have low hemoglobin and a huge splenomegaly.
- Hb: 8 gm
- WBCs: 62,000 / cmm, with abnormal cells: large nucleus,
many projections in the cytoplasm
What is the most likely diagnosis ??
QUESTION 3

A 42 year old male:
Recurrent upper respiratory inIections, with Iever, Submandibular
swellings.
He noted that cuts on his hands did not heal well.
The course oI his illness deteriorated very rapidly.
- Hb: 10 gm
- WBCs: 71,0001 cmm with abnormal cells.
- Platelets: 51,000/cmm

GIT CASES

- 15 - DR N.GWELY
QUESTION 4
A 6 year old male:
Recurrent upper respiratory inIections with Iever, Easy bruising, bony
pains.
Generalised LN, HSM, skin petichae.
- Hb: 9 gm
- WBCs: 92,000 / c mm, with abnormal cells.
- Platelets: 26, 000 I cmm

QUESTION 5
A 19 year old Iemale:
pallor, mild jaundice, splenomegaly. History oI cholecystectomy since
10 years.
He stated he had always had "low blood," and that
his Iather & paternal grandIather both had the same illness.
- Hb: 10.8 gm
- MCV: 84.1 FI
- Retix: 7
- Total Bil: 5.4 mg I dL
- Urea: 23 mg I dL (20 - 40 mg / dL)
Mention one important investigation at this point Answer:
QUESTION 6
A 32 year old Iemale, just aIter her second pregnancy:
Two day history oI ecchymoses, petechiae, hematuria.
She had behavioural changes, amnesia & mild icterus.
- Hb: 6.6 gm WBCs: 7,000 I cmm.
- Platelets: 14,000
- Total Bil: 3.2 mg I dL
- Urea: 68 mg I dL (20 - 40 mg / dL)
How would you treat this lady ??


- 16 - DR N.GWELY
QUESTION 7
A 41 year old male.
Almost 4 years prior to admission, he was diagnosed with a brain
tumor.
It was removed surgically and he received chemotherapy.
AIter about three years, the tumor recurred.
He was treated with radiation, and chemotherapy was resumed.
He now presented with Iever, pallor & bruises.
- Hb: 9.1 gm
- MCV: 68 FI
- Serum iron: ?
- WBCs: 2,300 I cmm
- Platelets: 51,000 / cmm
What is the most probable diagnosis ??
QUESTION 8
A 32 year old Iemale is reIerred by an oncologist Ior evaluation oI
bleeding tendency prior to LN biopsy.
Medical history reveals that she has had mild thrombocytopenia and a
positive Coombs` test in the past.
She also has skin rash & arthralgia.
- BT: 10 minutes,
- CT: 7 minutes,
- INR: 1
What is the most important test that you should do next ?


- 17 - DR N.GWELY
QUESTION 9

A 78 year-old male is reIerred to your oIIice with Iatigue, decreasing
energy, dyspnea, and a hematocrit oI 24.
His past history is signiIicant Ior oxygen dependant COPD, inoperable
coronary artery disease and a prosthetic aortic valve replaced 8 years
ago due to calciIic aortic stenosis.
On physical exam the patient is chronically ill.
A grade 2/6 systolic ejection murmur is heard at the base oI the heart,
radiating to the neck. There is mild clubbing oI the digits.
Stool is negative Ior occult blood.
Mention 2 tests you would ask ??
QUESTION 10
A male patient, 19 years old was investigated Ior his disease:
- Hb : 9gm
- Retix : 7
- MCV: 73FI
Mention one most important investigation at this point.
QUESTION 11
A Iemale patient, 21 years old was investigated Ior stroke:
- Hb: 8 gm
- Retix: 12
- MCV: 92 FI
- WBCs: 2500 / cmm
- Platelets: 80,000 / cmm
Mention one most important investigation at this point.
QUESTION 12
A male patient 17 years old presented to the hospital with general
maniIestations oI hemolytic anemia associated with dark coloured
urine
Enumerate the diIIerent possibilities ??


- 18 - DR N.GWELY
QUESTION 13
A Iemale patient 34 years old was investigated Ior his disease:
- Hb: 6 gm
- WBCs: 5,000 / cmm
- BLASTS
What is the most probable diagnosis ??
Mention 2 important investigations at this point.
QUESTION 14
Mention the CBC oI a patient with Addison`s disease Answer:
Increased: Lymphocytes, Basophils, Eosiophils
Decreased: RBCs, Neutrophils
Maybe: CBC oI pernicious anemia
QUESTION 30
A 37 year old Iemale, alcoholic.
LiIelong history oI a seizure disorder, treated since age two.
She was always advised to quit alcohol because oI her seizures.
At a routine check with his neurologist, he complained oI Iatigue,
exertional dyspnea, and lightheadedness over the past 2-3 months.
- Hb: 8.7 gm
- MCV: 112 FI
- Serum iron:
- What is the your initial test ??
QUESTION 38
A 43 year old Iemale. History oI Iibrocystic breast disease. Seen Ior
routine work-up prior to breast biopsy. Moderate splenomegaly, no
other organomegaly.
- Hb: 11.7 gm
- WBCs: 133,0001 cmm
- Platelets: 317,000/cmm
What is the your initial test ??
How would you conIirm your diagnosis ??

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