Uterine Fibroid - Case Study

History
A 36-year-old African-Caribbean woman has noticed abdominal swelling for 10 months. She has to wear larger clothes and people have asked her if she is pregnant, which she finds distressing having been trying to conceive. She has no abdominal pain and her bowel habit is normal. She feels nauseated when she eats large amounts. She has urinary frequency but no dysuria or haematuria.
Her periods are regular, every 27 days, and have always been heavy, with clots and flooding on the second and third days. She has never received any treatment for her heavy periods.
She has been with her partner for 7 years and despite not using contraception she has never been pregnant.

Examination
The woman has a very distended abdomen. A smooth firm mass is palpable extending from the symphysis pubis to midway between the umbilicus and the xiphisternum (equivalent to a 32-week size pregnancy). It is non-tender and mobile. It is not fluctuant and it is not possible to palpate beneath the mass. On speculum examination it is not possible to visualize the cervix. Bimanual examination reveals a non-tender firm mass occupying the pelvis.

Investigations
Haemoglobin = 6.3 g/dL ( normal = 11.7–15.7 g/dL)
Mean cell volume = 68 fL ( normal = 80–99 fL)

The pelvic ultrasound revealed a large uterine fibroid .

Case Discussion: 

Uterine Fibroid (Leiomyoma)
The woman has a large uterine fibroid (leiomyoma). This is causing menorrhagia and hence the microcytic anaemia from iron deficiency. It is also likely that the fibroid is accounting for her infertility history, although this warrants investigation as a separate
problem.
Fibroids are benign tumours of the myometrium which may be extrinsic (subserous) as in this case. Alternatively they may be intramural or submucosal (projecting into the endometrial cavity).

Adrenal Insufficiency - Case Study With Questions & Answers.

A 60-year-old man is hospitalized because of severe nausea, vomiting, and diarrhea of 4 days' duration. He admits to having experienced mild increasing fatigue and malaise for the last 6 months plus poor appetite, frequent abdominal cramps, and a 20-lb (9-kg) weight loss over the last 4 months. He feels dizzy in the morning and lightheaded after standing for more than an hour. He notes that he tends to take a nap in the late afternoon. Four days before presentation, abdominal cramps, vomiting, and diarrhea developed. He denies any skin changes and prolonged sun exposure. He admits to a decline in sexual desire. He has no history of hypertension, diabetes, asthma, or tuberculosis, and takes no medications.
Physical examination reveals a very tanned man, who appears acutely ill and some what dehydrated. He weighs 63 kg. His supine blood pressure (BP) is 106/68 mm Hg and his supine pulse is 90 beats per minute; his standing BP is 80/50 mm Hg and his standing pulse is 104 beats per minute.
His skin shows decreased turgor. His face, hands, extensor surfaces, chest, and back are notably tanned. The findings from the head, eyes, ear, nose, and throat examination are normal, except for the presence of hardened earlobes.
No heart abnormalities are noted and his lungs are clear.
Abdominal examination reveals the presence of diffuse tenderness, but no rebound or localized tenderness. The bowel sounds are hyperactive. There is decreased axillary hair. His testes are normal and central nervous system findings are unremarkable.

The following laboratory data are obtained:
hemoglobin (Hgb), 10.6 g, normochromic normocytic anemia;
white blood cell (WBC) count, 6,600 cells/mm3;
sodium, 128 mEq/L; potassium, 5.9 mEq/L; bicarbonate (HCO3-), 20 mEq/L; chloride, 96 mEq/L; 
creatinine, 2.0 mg/dL ; blood urea nitrogen (BUN), 39 mg/dL; and
calcium, 11.1 mg/dL.

The chest radiographic study findings are normal and the abdominal radiographic study show s a normal gas pattern, but bilateral adrenal calcification.
His electrocardiogram (ECG) is normal.

Seven months later, the patient becomes severely fatigued and weak and complains of cold intolerance, dry skin, somnolence, and constipation.
Physical examination at that time reveals a pale patient, with a supine BP of 110/60 mm Hg and supine pulse of 64 per minute. He weighs 72 kg. His skin is dry and warm and exhibits decreased turgor. Periorbital freckling and vitiligo are present, as well as mild, diffuse thyromegaly. Neurologic examination reveals generalized muscle weakness and decreased deep tendon reflexes symmetrically.

Laboratory data are as follows:
WBC, 6,900 cells/mm3 with normal differential;
serum sodium, 135 mEq/L; potassium, 4.7 mEq/L; chloride, 99 mEq/L; HCO3 -, 24.8 mEq/L; glucose, 78 mg/dL;
creatinine, 1.0 mg/dL; and BUN, 18 mg/dL.

Thyroid function tests reveal the following findings:
serum thyroxine (T4), 3.2 μg/dL (normal, 4 to 12 μg/dL);
triiodothyronine (T3) resin uptake, 20% (normal, 25% to 35%); and
TSH, 16 μU/mL (normal, 0.55.0 μU/mL).

The test result for antimicrosomal antibodies is positive, with a value of 1:50,000.

1. What is the most likely diagnosis in this patient?
2. What would be the first step in the diagnostic evaluation of this patient?
3. On the basis of the findings from the initial diagnostic evaluation, what is the diagnosis in this patient?
4. What would you recommend as an initial therapy?
5. How would you treat this patient's hypercalcemia?
6. What additional abnormalities may be seen in association with Addison's disease?
7. On the basis of the findings w hen the patient is seen 7 months later, what kind of thyroid disease does he have?
8. What is the most important advice to give this patient?

Answers And Discussion

Diagnostic Criteria For the Metabolic Syndrome

Diagnostic criteria for the metabolic syndrome include which of the following:

A. Peripheral obesity
B. High HDL-Cholestrol
C. Hypomagnasemia
D. Hypertriglyceridemia
E. Hyperphosphatemia


Answer :

The test of choice for the diagnosis of ureteral obstruction secondary to renal lithiasis is...

The test of choice for the diagnosis of ureteral obstruction secondary to renal lithiasis is
A) Noncontrast helical computed tomography (CT)
B) Ultrasound
C) Intravenous pyelogram
D) Magnetic resonance imaging (MRI)
E) Plain radiographs

Answer and Discussion

A 72 Year Old Woman With Shortness of breath and Abdominal Swelling ...

History
A 72-year-old woman has been admitted with shortness of breath. On further questioning she says she has been unwell for about 8 weeks. She has decreased appetite and nausea when she eats. She has lost weight but her abdomen feels swollen. She has generalized dull abdominal pain and constipation, which is unusual for her. There are no urinary symptoms.
She has always been healthy with no previous hospital admissions. She is a widow and did not have any children. Her periods stopped at 52 years and she has had no postmenopausal bleeding. She has never taken hormone-replacement therapy.
Examination
She appears pale and breathless on talking. Chest expansion is reduced on the right side, with dullness to percussion and decreased air entry at the right base. The abdomen is generally distended with shifting dullness. There is a mass arising from the pelvis. Speculum examination is normal, but on bimanual palpation there is a fixed left iliac fossa mass of about 10 cm diameter.

Investigations: 
Haemoglobin = 9.2 g/dL
CA-125 = 118 ku/L (normal <30ku/L)
Other routine blood work including liver function test and renal function was in normal range.

The Chest X ray shows An effusion on the right side and Ct scan of the abdomen and pelvis reveals a tumor on the left side and ascites.

Questions
• What is the likely diagnosis?
• How should this woman be further investigated?
• If the diagnosis is confirmed how should she be managed?

Answers And Discussion: 

Superior vena cava obstruction - Case Study

A 65 years old man  who is a smoker with no h/o hypertension or diabetes presented with frequent episodes of difficult breathing and cough for last 6 months. Cough is present throughout the day and night and is is usually dry, sometimes associated with scanty mucoid expectoration. He also noticed small amount of blood with sputum several times. The patient also complains of loss of appetite and substantial weight loss for the same duration. There is no history of fever, chest pain or contact with TB patients.
For the last few days, he has noticed gradual swelling of the face and arms along with shortness of breath, which is more marked on exertion. The patient also complains of headache which is
aggravated by cough and movement of the head for the same duration. He denies any change of
voice, back pain, yellow coloration of urine and sclera. His bowel and bladder habits are normal.
He smokes about 30 sticks/day for 25 years.

On Examination: the chest movement during respiration were decreased on the right side, and the percussion note was dull in the right upper chest. On auscultation of the lung fields, there were decreased breath sounds on the right upper chest, and few crepitations were heard throughout.
Heart sounds were normal.
Fundoscopy shows dilated vessels, hemorrhage and exudates.
Other systemic examination was normal.

Provisional Diagnosis: Superior vena cava (SVC) obstruction

Q. What do you think the cause of SVC obstruction in this case?
According to the age of the patient in this case 65 years old so causes are:

• bronchial carcinoma, 
• lymphoma

In young or early age—common cause is lymphoma.

Q. Tell one single investigation which will help the diagnosis of SVC obstruction.
Chest X-ray (which may show bronchial carcinoma and lymphoma).

Q. What investigations should be done in SVC obstruction?
 As follows:
1. Chest X-ray
2. CBC, ESR
3. Sputum for malignant cells
4. CT or MRI of chest
5. Others (according to suspicion of cause or physical findings):

•  If palpable lymph nodes FNAC or biopsy
•  Bronchoscopy and mediastinoscopy, venography and occasionally thoracotomy may be needed
•  Echocardiography in some cases.

Regarding Adrenal Insufficiency....

Regarding Adrenal Insufficiency answer the following questions:
1. What are the general categories of adrenocortical insufficiency?
2. Can you explain why thyroid function tests should be evaluated in a patient with primary adrenal failure?
3. What are the characteristic signs and symptoms of acute and chronic adrenal insufficiency?
4. What criteria are used to make the diagnosis of adrenal insufficiency?
5. What are the considerations in deciding on long-term replacement therapy for Addison's disease?
6. What other metabolic abnormalities may occur in association with adrenal insufficiency?
7. What are the events that take place in the regulation of cortisol secretion by the hypothalamic–pituitary–adrenal axis?
8. What are the specific causes of primary and secondary adrenal failure?

Answers And Discussion

1. What are the general categories of adrenocortical insufficiency?
Adrenocortical insufficiency results primarily from deficient cortisol production and in some cases deficient aldosterone and androgen production by the adrenal gland. Because the adrenal cortex is normally stimulated by pituitary adrenocorticotropic hormone (ACTH; corticotropin), cortisol
deficiency may result from adrenal disease (primary adrenal insufficiency or Addison's disease) or from pituitary or hypothalamic disease with ACTH deficiency (secondary adrenal insufficiency).

Secondary Infertility Due To Premature Ovarian Failure..

History
A 37-year-old woman is seen in the clinic because of  secondary infertility. She had a daughter 13 years ago and a miscarriage 2 years later. She separated from her former husband and has now married again and is keen to conceive, especially as her new partner has no children.
Her last period started 45 days ago. She says that her periods are sometimes regular but at other times she has missed a period for up to 3 months. The bleeding is moderate and lasts up to 4 days. There is no history of pelvic pain or dyspareunia, and no irregular bleeding or discharge.
There is no medical history of note and she takes no regular medication.
Her partner is 34 years old and is also fit and healthy with no significant history of ill-health or medications.

Examination
There are no abnormal features on examination of either partner.

Investigations:
Day 3 follicle-stimulating hormone (FSH) = 11.1 IU/L ( normal on day 2-5 = 1–11 IU/L)
Prolactin = 305 mu/L (normal = 90–520 mu/L)
Day 21 progesterone = 23 nmol/L ( >30nmol/L if ovulation occurs)

Semen analysis report: normal volume, count, normal forms and motility.

Hysterosalpingogram report: the uterine cavity is of normal shape with a smooth regular outline. Contrast medium is seen to fill both uterine tubes symmetrically and free spill of dye is confirmed bilaterally.

Transvaginal ultrasound scan report: the uterus is anteverted with no congenital abnormalities, uterine fibroids or polyps visualized. Both ovaries are of normal morphology, volume and mobility. No follicles are noted.

Questions
• What is the cause of the infertility?
• What are the further investigation and management options?

Answers And Discussion

An isolated hyperbilirubinaemia in a 22-year-old male...

A 22-year-old male with no history of any illness comes to donate blood. His blood work before donation shows following results:

• Bilirubin 41 μmol/L 
• Alkaline phosphatase 84 U/L 
• ALT 23 U/L 
• Albumin 41 g/L 

Dipstick urinalysis normal

What is the most likely diagnosis?
A. Gilbert's syndrome
B. Dubin-Johnson syndrome
C. Rotor syndrome
D. Hepatitis C infection
E. Infectious mononucleosis

Answer:

Features Suggesting Poor prognosis In patients With Schizophrenia

Regarding a patient diagnosed with schizophrenia answer the following question:

Answer And Discussion:

Primary Infertility Case Study

A 29-year-old woman and her partner are seen in the gynaecology outpatient clinic with primary infertility. They stopped using condoms 2 years ago and have had regular intercourse since then. The partner has no previous medical history of note.  He works as a manager in a hotel.
The woman also has no specific previous medical history except for an appendectomy aged 12 years. Her periods occur every 31 to 46 days and can be heavy at times but not painful. There is no intermenstrual or postcoital bleeding. She has always had normal smears and has never had any sexually transmitted infections. She takes no medications,

Examination
On examination her body mass index (BMI) is 29 kg/m2. She has slight acne on her face and her chest. There are no abdominal scars and the abdomen is non-tender with no masses palpable.
Speculum and bimanual examination are normal.

Investigations
 - Day 3 luteinizing hormone (LH) = 6.2 IU/L (Normal on day 2-5 = 0.5–14.5 IU/L)
 - Day 3 follicle-stimulating hormone = 3.1 IU/L (Normal on day 2-5 =1–11 IU/L)
 - Day 21 progesterone = 15 nmol/L (>30nmol/L if ovulation occurs)
 - A transvaginal ultrasound scan shows polycystic ovaries.

Questions
• What is the diagnosis?
• How would you further investigate and manage this woman?

Answers And Discussion

Mitral Stenosis - Case Study With Questions & Answers

A 32-year-old woman who recently moved to the United States from Mexico is seen because of the recent onset of palpitations associated with dyspnea on exertion, orthopnea, and paroxysmal nocturnal dyspnea with hemoptysis.
On physical examination, her blood pressure is 112/90 mm Hg and her heart rate is 120 per minute and irregularly irregular. Jugular venous distention to 10cm H2O with a prominent V w ave is noted, as are diminished arterial pulses and bibasilar rales (up to half of the lung fields bilaterally). Additional findings include a nondisplaced apex beat, a right ventricular heave palpable in the left
parasternal region, a palpable pulmonic closure sound in the second left intercostal space, an accentuated S4, a loud pulmonic second sound (P2) over the left ventricular apex, a snapping sound over the left ventricular apex impulse just after the second heart sound, and a grade 3/4, low -pitched,
rumbling, nearly holodiastolic murmur heard best at the cardiac apex. There is 1 to 2+ pitting edema noted in the lower extremities and presacral area.

1. What is the most likely valvular lesion in this patient?
2. What is the most common cause of mitral stenosis in adult patients?
3. What is the mortality rate associated with medically treated mitral stenosis?
4. What are the major complications of mitral stenosis?
5. What is the best treatment for symptomatic patients with mitral stenosis?

Answers:

Regarding Antiemetic During Migraine Attack ...

You want to prescribe an antiemetic to a 19-year-old female who is having a migraine attack. Which one of the following medications is most likely to precipitate extrapyramidal side-effects?
A. Meptazinol
B. Ondansetron
C. Domperidone
D. Cyclizine
E. Metoclopramide

Answer:

A 29-yr-old man is admitted to hospital with a rash and high fevers....

A 29-yr-old man from Srilanka is admitted to hospital with a rash and high fevers. He gives a long history of pains in his hands and feet.
On Examination, he has an erythematous rash over his nose and cheeks.
ANA testing and dsDNA are strongly positive.
As part of his screening for pyrexia of unknown origin, an HIV antibody test is carried out, which proves positive.
His blood results are as follows:
Na, 136 mmol/l;
K, 3.7 mmol/l;
Urea, 3.5 mmol/l;,
Creatine, 67 U/l;
LFTs, normal;
Hb, 12.9 g/dl;
WCC, 2.4× 109/l (lymphocytes 0.8 × 109/l);
Platelets, 200 ×106/l;
ANA, positive;
dsDNA, positive;
CD4, 80 cells/mm3;
HIV antibody, positive;
Blood cultures, negative;
Syphilis serology, negative.

What is the most appropriate treatment  for his rash and arthropathy?
A. Combivir, efavirenz, co-trimoxazole
B. Prednisolone
C. Combivir, efavirenz, co-trimoxazole, prednisolone
D. Prednisolone, co-trimoxazole
E. Combivir, efavirenz

Answer:

A 56-year-old man is seen because of progressive fatigue, dyspnea on exertion, orthopnea, and paroxysmal nocturnal dyspnea. ..

A 56-year-old man is seen because of progressive fatigue, dyspnea on exertion, orthopnea, and paroxysmal nocturnal dyspnea.
On physical examination his blood pressure is 160/60 mm Hg. There is no jugular venous distention, but systolic pulsations of the uvula are noted, as is quick collapse of the arterial pulses, which is seen in the nail beds with gentle pressure. The lungs are clear to percussion and auscultation. There is a diffuse and hyperdynamic apex beat that is displaced laterally and inferiorly, soft first and second heart sounds, a loud third heart sound, and a grade 3/6, high-pitched, nearly holodiastolic murmur heard best at the upper left sternal border along with a grade 3/6 systolic ejection type murmur at the upper left sternal border radiating to the carotids. A late diastolic rumble is heard at the apex as well
as a third heart sound.

1. What is the most likely valvular lesion in this patient?
2. What is the likely underlying cause of aortic regurgitation in this patient?
3. What is the appropriate medical therapy for the patient with aortic regurgitation?
4. When should aortic valve replacement be considered in a patient with chronic aortic regurgitation?
5. What is the surgical therapy for severe aortic regurgitation?

Answers:

1. What is the most likely valvular lesion in this patient?
This patient has chronic severe aortic regurgitation.

There are many physical signs to look for in the setting of aortic regurgitation, some of which are
seen in this patient. These include

• de Musset's sign (the head bobs with each heartbeat), 
• Corrigan's sign or waterhammer pulses, 
• Traube's sign (booming systolic and diastolic sounds heard over the femoral arteries),
• Muller's sign (systolic pulsation of the uvula), 
• Quincke's sign (capillary pulsations seen in the nail beds), and others. 

All of these are signs of large stroke volume and wide pulse pressure characteristic of chronic aortic
regurgitation. The loud 3/6 diastolic murmur heard at the upper left sternal border is the murmur of aortic insufficiency and the systolic murmur is due to turbulent flow across the aortic valve because of the large amount of blood crossing the aortic valve. The mid-to-late diastolic rumble, namely the Austin Flint murmur, is created by rapid retrograde flow from the aorta striking the anterior mitral leaflet. Another explanation for this murmur is that the large volume of regurgitant flow partially closes the mitral valve, creating a late diastolic mitral valve gradient.

A 32 year Old woman presents with absent periods for 3 months......

A 32-year-old woman complains that she has not had a period for 3 months. Four home pregnancy tests have all been negative. She started her periods at the age of 15 years and until 30 years she had a normal 27-day cycle. She had one daughter by normal delivery 2 years ago, following which she breast-fed for 6 months. After that she had normal cycles again for several months and then her periods stopped abruptly. She was using the progesterone only pill for contraception while she was breast-feeding and stopped 6 months ago as she is keen to have another child. She reports symptoms of dryness during intercourse and has experienced sweating episodes at night as well as episodes of feeling extremely hot at any time of day.

There is no relevant gynaecological history.

The only medical history of note is that she has been hypothyroid for 10 years and takes thyroxine 100 μg per day.

She does not take any alcohol, smoke or use recreational drugs.

Examination findings are unremarkable

Investigations:
Haemoglobin  = 12.2 g/dL (normal = 11.7–15.7 g/dL)
Thyroid-stimulating hormone = 3.6 mu/L (normal = 0.5–7 mu/L)
Free thyroxine = 28 pmol/L (normal =  11–23 pmol/L)
Follicle-stimulating hormone = 45 IU/L
Luteinizing hormone = 30 IU/L
Prolactin  = 401 mu/L (normal = 90–520 mu/L)

Questions
• What is the diagnosis?
• What further investigations should be performed?
• What are the important points in the management of this woman?

Answers and Discussion

Pneumothorax - Long case study With Questions & Answers

Presenting Complains: 

• Breathlessness for … days
• Right sided chest pain for … days
• Cough for … days.

History of present illness: According to the statement of the patient, he was alright … days back. Since then, he suddenly felt severe breathlessness associated with pain in right side of his chest.

Breathlessness is present in rest, more marked on lying on right side and also on lying flat. It is nonprogressive, not associated with wheeze and does not relieve by taking rest or drugs. He also complains of right sided chest pain, which is sharp and stabbing in nature, aggravated by deep breathing, coughing, with movement and lying on right side but no radiation. The patient also complains of cough with slight mucoid expectoration but no hemoptysis. There is no history of trauma or fever.

History of past illness: There is no history suggestive of COPD, or chronic bronchitis or bronchial

asthma. There is no previous attack of such illness.

Family history: Nothing contributory.

Socioeconomic history: He is a laborer, living in a slum area with poor sanitary facilities.

Personal history: He smokes 30 to 40 sticks/day for 20 years, but nonalcoholic.

General Physical Examination: 

• The patient appears anxious and slightly dyspneic
• Decubitus: patient prefers to lie on left lateral position
• He is mildly anemic
• No jaundice, cyanosis, edema, clubbing, koilonychia or leukonychia
• No lymphadenopathy or thyromegaly
• Respiratory rate: 34/min
• BP: 110/80 mm Hg
• Pulse: 108/min.

Respiratory System:(supposing right side)

- Inspection:

• Restricted movement on right side of the chest
• Intercostal spaces appear full.

- Palpation:

• Trachea—deviated to the left
• Apex beat—in left 6th intercostal space in anterior axillary line (shifted to left), normal in character
• Vocal fremitus—reduced in right side but normal on the left side
• Chest expansion—reduced on the right side of the chest.

 - Percussion: 

• Hyper-resonance in right side (tell where), but normal on the left side
• Upper border of the liver dullness—in the right 6th intercostal space in the midclavicular line.

 - Auscutation:

• Breath sound—diminished (or absent) on the right side of the chest (tell up to which space), but vesicular on the left side.
• Vocal resonance—diminished (or absent) on the right side of the chest (tell up to which space), but normal on the left side.

Examination of other systems reveals nothing abnormal.

1. What is your diagnosis?

Regarding Screening For Hepatocellular Carcinoma?

Which one of the following patients is most likely to require screening for hepatocellular carcinoma?
A. A 45-year-old man with liver cirrhosis secondary to hepatitis C
B. A 33-year-old man with HIV. He is taking antiretroviral therapy
C. A 22-year-old man with alpha-1 antitrypsin deficiency. He has no evidence of current liver disease
D. A 52-year-old woman with alcohol-related liver cirrhosis who is still drinking
E. A 75-year-old man who drinks 100 units / week. He has no current signs of liver disease

Answer:

A 31 Year Old Woman Presents With Difficulty Conceiving....

A 31-year-old woman has been trying to conceive for nearly 3 years without success. Her last period started 7 months ago and she has been having periods sporadically for about 5 years. She bleeds for 2–7 days and the periods occur with an interval of 2–9 months. There is no dysmenorrhoea but occasionally the bleeding is heavy.
She was pregnant once before at the age of 19 years and had a termination of pregnancy.
She had a laparoscopy several years ago for pelvic pain, which showed a normal pelvis.
Cervical smears have always been normal and there is no history of sexually transmitted infection.
The woman was diagnosed with irritable bowel syndrome when she was 25, after thorough investigation for other bowel conditions. She currently uses metoclopramide to increase gut motility, and antispasmodics.
Her partner is fit and well, and has two children by a previous relationship. Neither partner drinks alcohol or smokes.

Investigations: 
Follicle-stimulating hormone = 3.1 IU/L ( Normal = Day 2–5 1–11 IU/L)
Luteinizing hormone = 2.9 IU/L ( Normal = Day 2–5 0.5–14.5 IU/L)
Day 21 progesterone = 12 nmol/L (>30nmol/L indicates ovulation)
Prolactin = 1274 mu/L ( Normal = 90–520 mu/L)
Thyroid-stimulating hormone = 4.1 mu/L ( Normal = 0.5–7 mu/L)

1. What is the diagnosis and its etiology?
2. How would you further investigate and manage this couple?

Answers And Discussion:

Mitral Regurgitation - Questions And Answers

A 50-year-old woman who had an “innocent” murmur diagnosed in childhood presents with dyspnea on exertion, orthopnea, and paroxysmal nocturnal dyspnea of several months' duration. On questioning, she describes a 1-year history of fatigue and exhaustion that has limited her daily activities. She has not seen a physician in years.
On physical examination, her blood pressure is 110/70 mm Hg. Her jugular venous pressure is normal and she has mildly diminished arterial pulse amplitude with a normal arterial upstroke. Her lungs are clear to percussion and auscultation. There is a laterally displaced apex impulse and a palpable third heart sound that is easily heard. The first heart sound is soft and there is a widely split second heart sound with normal respiratory splitting. A grade 3/4 blowing, high-pitched systolic murmur is heard at the apex and radiates to the axilla and left infrascapular area. There is trace edema but no clubbing or cyanosis.

1. What is the valvular lesion in this patient?
2. What is the most common underlying cause of severe mitral regurgitation in the adult U.S. population?
3. Does medical therapy prevent progression of mitral regurgitation?
4. When should surgery be considered for patients with severe mitral regurgitation?
5. What are the choices for mitral valve surgery?

Answers :

A 65 Year Old Man Known Case Of Rheumatoid Arthritis develops A Pleural Effusion...

A 65-yr -old man with severe RA is admitted with a right pleural effusion. He has been
complaining of dyspnoea on exertion for the last three months. He has never smoked and has not
worked for over 20 yrs when he was diagnosed to be suffering from rheumatoid arthritis. Which
of the following is true?
A. Pleural effusions with RA occur in over 50% of pts
B. A glucose level in pleural fluid of < 1.6 mmol/l is characteristic of a rheumatoid pleural effusion
C. Pleural effusions associated with RA have low levels of cholesterol
D. The most appropriate Rx is chemical pleurodesis
E. Bilateral pleural effusions do not occur in RA

Answer:

A 48-year-old woman presents with intermenstrual bleeding for 2 months

A 48-year-old woman presents with intermenstrual bleeding for 2 months. Episodes of bleeding occur any time in the cycle. This is usually fresh red blood and much lighter than a normal period. It can last for 1–6 days. There is no associated pain. She has no hot flushes or night sweats. She is sexually active and has not noticed vaginal dryness.
She has three children and has used the progesterone only pill for contraception for 5 years. Her last smear test was 2 years ago and all smears have been normal. She takes no medication and has no other relevant medical history.

Examination
The abdomen is unremarkable. Speculum examination shows a slightly atrophic-looking vagina and cervix but there are no apparent cervical lesions and there is no current bleeding.
On bimanual examination the uterus is non-tender and of normal size, axial and mobile. There are no adnexal masses.

Investigations: 
Haemoglobin 12.7 g/dL (Normal range 11.7–15.7g/dL)

Transvaginal ultrasound scan and hydrosonography is shows an endometrial polyp.

Questions
• What is the diagnosis and differential diagnosis?
• How would you further investigate and manage this woman?

Answers And Discussion:

Bronchial Carcinoma - Long Case Discussion With Questions & Answers.

Mr …, 52 years old, a clerk, normotensive, nondiabetic, smoker, hailing from …, presented with
frequent cough for … months, which is present throughout the day and night. The cough is usually
dry, sometimes associated with slight mucoid sputum expectoration. Occasionally, the patient noticed
streaks of frank blood with sputum during coughing. There is one episode of massive hemoptysis …
days back. For the last … days, he is also complaining of right sided chest pain, which becomes worse with deep inspiration, coughing and also on lying down on right side. The patient also complains of loss of appetite, substantial loss of weight, weakness and malaise for ... days. His bowel and bladder habits are normal. There is no history of fever, hoarseness of voice, difficulty in deglutition, contact with TB patients. He smokes about 25 sticks a day for the last 30 years. He used to take some cough syrup and occasionally antibiotics, the name of which he cannot mention.

Examination:
Respiratory System
(Supposing right sided)
Inspection:

• Movement is restricted on right upper chest
• There is radiation mark on the chest (if any).

Palpation:

• Trachea is central in position
• Apex beat is in left 5th intercostal space, just medial to the midclavicular line
• Vocal fremitus is reduced (or absent) in right upper chest
• Pleural rub is present (mention where).

Percussion:

• Percussion note is dull in right upper chest (mention up to which space)
• Upper border of the liver dullness is in the right 5th intercostal space in the midclavicular line
• Cardiac dullness is normal.

Auscultation:

• Breath sound is reduced (or absent)
• Vocal resonance is reduced (or absent)
• Few crepitations (may be present)
• Pleural rub is present (mention where).

Examination of the other systems reveals no abnormalities.

1. What is your diagnosis? 
My diagnosis is bronchial carcinoma with metastasis (in right supracalvicular Lymph node).

2. Why bronchial carcinoma?
The patient is elderly and heavy smoker. There is history of cough with hemoptysis and marked loss
of weight. On examination, the patient is emaciated, has generalized clubbing with nicotine stain and
examination of chest shows evidence of mass lesion. All the features are suggestive of bronchial carcinoma.

3. What are your differential diagnoses?
As follows:

• Pulmonary TB
• Other mass lesion (hydatid cyst, dermoid cyst, neurofibroma).

4. Why pulmonary TB is not your primary diagnosis?
This may be pulmonary tuberculosis, because all the features like cough, hemoptysis and weight
loss are present in tuberculosis. However in this case, there is no history of fever or contact with TB
patient. The patient has gross clubbing, enlarged supraclavicular lymph node, which is hard in
consistency and evidence of mass lesion in chest. All these are against pulmonary tuberculosis.

A Previously Healthy 42 Year old Man Presents To The Emergency With Syncope

A previously healthy but inactive 42-year-old man is seen in the ER after a first episode of syncope, which occurred while he was playing basketball.
On questioning, he describes a 2-month history of exertional chest pain. He has not seen a physician during his adult life.
Physical examination reveals the following findings. His supine blood pressure is 116/80 mm Hg without any significant orthostatic change. There is no jugular venous distention, but there are slowly rising, small-amplitude, and somewhat sustained carotid pulses. His lungs are clear. A sustained and slightly laterally displaced apex impulse is noted, as well as a soft first heart sound and a single second heart sound, a prominent fourth heart sound, and a grade 3/6 harsh, late-peaking, crescendo–decrescendo systolic murmur heard best at  the cardiac base and radiating to the carotids with a high-frequency component at the cardiac apex. No clubbing, cyanosis, or edema is noted.

1. What is the most likely valvular lesion in this patient?
2. What is the most likely cause of aortic stenosis in this age-group?
3. What is the average survival of patients w ith uncorrected aortic stenosis
after the onset of syncope?
4. How is the severity of aortic stenosis most accurately determined?
5. What is the best therapy for symptomatic aortic stenosis?

Answers:

1. What is the most likely valvular lesion in this patient?
The history of angina and syncope and the classic physical examination findings make aortic stenosis an almost certain diagnosis in this patient.
The characteristic arterial pulses described have been referred to as pulsus parvus et tardus. The single second heart sound indicates the absence of the aortic component, suggesting severe immobility of the aortic valve. The murmur is also characteristic of aortic stenosis with its crescendo– decrescendo quality and the late peaking. Do not be fooled by the high frequency
component at the cardiac apex. Although the murmur of aortic stenosis is most often heard at the upper cardiac border with radiation to the carotid arteries, the murmur may also radiate to the apex, where it may be mistaken for the murmur of mitral regurgitation.