A young woman of 24 went to her GP saying that for the last two or three weeks she had felt

feverish and unwell with a sore throat. Apart from a tonsillitis the only other finding noted was a slightly tender enlarged gland in the neck. She was started on ampicillin but stopped this two days later because of a skin rash. She continued to feel generally unwell over the next two weeks and returned to see her doctor found Hb 10.1g/dl. WBC 7,000/mm3 (2% atypical monocytes. Platelets 155,000/mm3. ESR 35.

She was treated with iron and multivitamins but continued to deteriorate and become weaker. Three weeks later when she was admitted to hospital her blood was Hb 4.5g/dl. WBC 2,000/mm3. platelets 90,000/mm3. There was no lymphadenopathy and no abnormal physical signs. 1. What are the two most likely diagnosis? 2. What are the 3 most useful investigations?

A 71 year old farmer went to his GP complaining of low backache, lethargy and recent weight loss. It had come on gradually and had worsened over the last two months. He described it as a constant nagging pain that was not related to posture so that he found it impossible to lie or sit comfortably. There was no radiation of the pain to his legs or groin. There was a vague tenderness in the region of the 3rd and 4th lumbar vertebrae made worse by jarring. On examination movement of the spine were full and not painful.

1. 2.

Straight leg raising was normal. There were no abnormal physical findings elsewhere. Xrays of the lumbar spine and pelvis showed no boy abnormality but he had a Hb 10g/dl. And ESR 120. What are the 3 most likely diagnoses ? What would be the 6 most useful investigations?

A man of 54 presented with earache, tinnitus and deafness in his left ear for several days. That day he said he found it difficult no to dribble and had noticed watery blisters on his left ear On Examination he was found to have a left lower motor neurone lesion of the seventh nerve and left nerve deafness together with cutaneous vesicles in the eternal auditory meatus and a few ulcerating lesions on the left soft palate.

Physical examination was otherwise entirely normal. Investigations showed: Hb 12.2g%, WBC 7,300/mm3. ESR 86, CXR is normal. Urea 43 mg%, Na 137 mEq/l , K 4.2 mEq/l, Ca 9.9mg% , phosphorus 3.2 mg%, bilirubin 0.9mg% , alkaline phosphatase 12KA units , albumin 3.2 g%, globulin 6.4 g%, electrophoresis an abnormal peak in the globulin range.

What was the cause of his earache? 2. What was the cutaneous nerve supply of the area involved ? 3. Suggest the 4 most useful investigations indicated in view of his high globulin.
1.

A 50 years old Indian epileptic woman. Who had been well controlled on phenytoin for many years, came to medical outpatients with a 3 month history of tiredness and a 3 weeks history of mild watery diarrhea. In her past medical history she had had TB treated with triple chemotherapy ten years previously. OE: the only abnormal finding were that she was clinically anaemic and thin.

Investigation showed : Hb 8g/dl, MCV 112 fl , ESR 60 , B12 60ng/l. folate 60 g/l. faecal fats 28 mmol/24h
What is your diagnosis Suggest the 6 most useful investigation that should be carried out.

1. 2.

a 48 year old woman had been working in an east African mission hospital for 3 years where she had looked after the physiotherapy and radiology departments where she had worked 2 afternoons a week. Following an attack of a diarrhea she went to her doctor and was found to have a Hb 8.2g% , WBC 2300/mm3 (70% lymphocytes ), platelets 60,000/mm3 . There was no history of drug ingestion in any form. She was not on a contraceptive pill and did not take any malaria prophylaxis . Apart from being pale there were no abnormal physical signs and a bone marrow biopsy showed a uniform decrease in all elements with fatty replacement , no abnormal cells were seen

1. 2. 3.

It was felt she should stop working in the radiology department . She continued to be pale and 6 month later she returned to England where she was given unknown quantity of iron , folic acid and vitamin B12. on year after her return to England she was seen in Out patients where she was found to have Hb 6.2 g/dl , WBC 1800/mm3 (lymphocyte 65%) , platelets 60,000/mm3 . A splenic tip was palpable careful examination but there was no hepatomegaly and no other abnormal signs. Two attempts at sternal marrow biopsy was unsuccessful. What are the 3 most likely diagnoses? What would be the 4 most useful investigations? How would you monitor the progress ?

A 37year old woman with CRF had received a cadaveric renal transplant 5 years previously. Early rejection episodes had been treated successful with steroid and azathioprine and for the past 2 years she had remained well on a maintenance dose of these 2 drugs. 3 weeks before admission she had begun to feel ill with anorexia, loss of weight and sweating. For the past 2 days her urine become dark and her husband said that her skin had become yellow and that she was confused

On Examination she was ill , confused and icteric/ she had fever of 39 and a tremor was noted. The pulse was 105 bpm , BP ws 110/70 mmHg, JVP and heart were normal / the lungs were clear. In the abdomen the liver was palpable , tender and 4 cm enlarged. Investigation showed Hb 9.9g%, WBC 12,000/mm3 , urea 40mg% , Na 137 mEq/l, K 4.3 mEq/l, Bil 14mg% , SGOT 430 IU/L , alkaline phosphatase 29 KA units, S. Alb 2.9g% , globulin 4.7g%


1. 2.

Urine : urobilinogen +ve , bilirubin +ve give 6 possible causes for her jaundice What 6 immediate investigations are indicated?

A 4 year old boy was brought by his parents to the family doctor. They thought he might be backward in speech and behavior and were worried. On further questioning the doctor was told that the boy was passing large quantities of urine and was always thirsty. In his past medical history he had had a fit at eighteen months but had not been investigated for this. A brother had died aged 4 months

1. 2. 3.

O/E: the child was sick and dehydrated and did indeed appear mentally backward. There were no abnormal finding elsewhere. He was admitted to hospital for investigation and observation. Urine analysis showed no protein or glucose and his IVP was normal. Give the most likely diagnosis What 5 investigations are appropriate in this case? What 2 steps would you include in his management?

A woman of 25 went to see her GP as she had developed intermittent fever , muscle pains , listlessness and had felt unwell for 3 weeks O/E she was pyrexial (38) and had several slightly tender enlarged lymph glands in her neck. The only other abnormal findings were that she had a palpable liver and the spleen tip was also felt. In her left groin she had some enlarged lymph glands. The rest of the examination was normal.

1. 2.

Investigation: Hb 13 g%, ESR 40 , WBC 6,000/mm3 (50% lymphocutes) , platelets 250,000/mm3 . Film showed some abnormal mature monocytes. LFT: SGOT 80 I.U,Bil 1mg% , alkaline phospatase 15 KA units , Paul Bunnel test is negative , CXR is normal Give 5 differential diagnosis. What are the 5 most useful investigation?

A 77 year old spinster was admitted to hospital with a 10 days history of vomiting , abdominal pain and dysuria. She had been treated initially by her GP with co-trimoxazole (septrin); when she showed no response to this she was given a subsequent course of tetracycline. She was a late onset diabetic controlled by cholropropamide 250mg daily and a diet. During the last 2 or 3 days before admission she had 2% glycosuria but no ketonuria.

in her past medical history she had had intermittent UTI which normally responded to treatment. The only other fact of note was that she had suffered for many years from frequent headaches for which she took proprietary analgesics. O/E: she had a healing erythematous rash on her arms . The rest of her examination was normal a part from her blood pressure of 180/100 mmHg and grade II hypertensive changes in the retinal vessels.

Investigation: Hb 11g%, urea 250mg% , Na 130mEql/l , K 5 mEql/l, urine culter showed growth of Ecoli sensitive to nalidix acid. She was treated with nalidixic acid to which she responded well and a week later she was symptom free and her blood urea was 110mg% 3 weeks later she develop a further attack of pain and dysurea and suddenly developed anuria

1.

2. 3.

suggest 2 ways in which the drug therapy has contributed to her renal failure How might the AB have influenced her control of DM Suggest 2 other possible causes for her anuria

A 23 year old, builder presented with a fever , pleuritis and cervical lymphadenopathy . No other abnormalities were found on examination. A histological diagnosis of Hodgkins disease was made from a lymph node biopsy. What 3 steps in the management of this patient would you consider at this time ?

With specific therapy remission was obtained. 6 months later he returned with fever , malaise and a cough productive of white sputum . His GP had prescribed ampicillin. His condition worsened and on admission to hospital CXR showed patchy consolidation in the right upper and mid zones and in the left mid zone. Sputum culture grew a few Candida only blood culture was negative

Despite vigorous antibiotic therapy he deteriorated and died 5 days later 1. Give 3 causes for his relapse 2. What 4 investigations would you have performed on his 2nd admission

A 19 year old typist presented with a 4 day illness of fever. Sweating , pain ad weakness in the left shoulder and left upper arm. She had previously been in a good health except for a 3 day episode of lower abdominal pain two weeks previously. Which was associated with some vaginal discharge and for which she was prescribed amipicillin by her GP . In reference to a VD clinic no evidence of venereal infection was found.

O/E she had a pyrexia of 39.5 and was obviously ill. There was severe pain and localized tenderness over the left scapula and left humerus where firmed swellings were palpable. Movement of the arm was severely restricted by pain. The skin was hot and reddened and fasciculation was noted. Investigation showed Hb 13g%, WBC 14,000/mm3 , ESR 70 , CXR of should joint and humerous showed no abnormality . EMG: showed polyphasic potentials with increased insertion activity

1.
2.

Give 4 further investigations Give 2 possible diagnosis

An 82 year old male had been admitted for 4 times in the previous year for malaise , lethargy and extreme pallor. On each occasion he had be found to be anemic but apart from invariable finding of +ve occult blood, no definitive diagnosis had been made. During this period he had received several course of oral iron and on 2 occasions he was transfused for pints of Packed RBCs. He smoked 10 cigarettes a day , drank 2 or 3 whiskies each evening and ate reasonable foods.

On he latest admission examination revealed pallor but no jaundice , lymphadenopathy , or clubbing and no signs of chronic liver disease. His pulse was 80 bpm regular rhythm , BP 170/95 mmHg , JVP normal, the heart sounds were unremarkable and the respiratory system was normal. In the abdomen the liver was enlarged 3 cm below the right costal margin and the spleen 2 cm below the left costal margin. Rectal examination was normal

Investigation showed: Hb 7gm% , WBC 6,000/mm3 , reticulocyte 4%, ESR 25 , Urea and electrolyte Normal , S.Iron 4.9umol/l, TIBC 80umol/l, Serum B12 and folate were normal. Barrium swallowing meal, follow through and enema were normal, Sigmoidoscopy revealed no abnormality and occult blood was persistently +ve.

Give 4 possible causes for this anemia 2. Give 2 likely causes for the splenomegaly 3. What 2 further investigation would you undertake
1.

A 28 year old women journalist went to see her GP as the she had been feeling unwell. For 6 weeks with anorexia , lethargy, joint pain and a loss in weight of more than a stone. O/E she was thin , pale , pyrexial and jaundiced. Her abnormal physical findings were confined to her abdomen were she had a palpable liver 3 cm below her right costal margin. And the tip of the spleen was also palpable

Investigations: Hb 11g%, WBC 6000/mm3 ,Bil 2mg%, Alkaline phosphatase 20 KA units, SGOT 800 IU, Albumin 2.4 g% , Globulin 4.3 g%. 1. What 2 further points from her history should be documented? 2. Give 5 possible diagnosis 3. What 5 further investigation would help you establish a diagnosis?

A 78 year old lady was admitted for investigation, for the past two months she had been generally unwell, lethargic and anorectic and complaining of generalized muscular pains and Arthralgia in shoulders, hips and wrists. Her general practitioner had tried her on an Iron/folate combination after vitamin tablets had not improved her symptoms. On the week before admission she had become slightly confused at night with a tendency to fall. Past medical history included a Cholecystectomy 30 years ago and a Myocardial Infarction 6 years previously, from which she had made a good recovery. She had been on Bendrofluazide (10 mg) daily since her Myocardial Infarction. On examination she was well orientated, with a temperature of 37.3 C. Her conjunctivae were pale with two small petechiae on the left. She was not cyanosed or dyspneic. Her BP was 160/95 mmHg, pulse: 100 beats/min and regular with a fair volume. The left ventricle was enlarged. The heart sounds were normal with a soft pansystolic murmur at the apex. Her respiratory system was normal, and in the abdomen the spleen tip was just palpable. The central nervous system was normal, with no proximal muscle weakness. General examination showed osteoarthritis of the left knee and Heberden nodes on the fingers. Both temporal arteries were palpable and non-tender. Investigations showed: Hb 9.8 g/dl, MCV 86 fl, MHCH 30 g/dl, WBC 8.6x109/l, platelets 470x109/l, ESR 78 mm/h, Urea and electrolytes and liver function tests were normal. Chest X-Ray showed left apical calcification and moderate cardiomegaly. Serum B12 and red cell folate were normal. Serum iron was 10 umol/l Total Iron Binding Capacity was 36 umol/l MSU showed four red cells/high powered field, with no growth. What is the diagnosis? How would you confirm the diagnosis and give 6 other useful investigations.