A 75-year-old woman presents with a chief complaint of cough while eating

 A 75-year-old woman with a history of diabetes mellitus, hypertension, hyperlipidemia, and peripheral artery disease presents with a chief complaint of cough while eating. On further history, she describes trouble initiating her swallow as well as recent dysarthria.

Which of the following is the most likely cause of her symptoms?

A. Achalasia

B. Esophageal web

C. Stroke

D. Zenker diverticulum

Answer:

A 75-year-old man with a history of hypertension and peptic ulcer disease presents with dyspnea on exertion

 A 75-year-old man with a history of hypertension and peptic ulcer disease presents with dyspnea on exertion to the emergency department (ED). He notes black-colored stools for the past 2 weeks. His initial examination is notable for conjunctival pallor, clear lung fields without rales, wheezing, or rhonchi, as well as tachycardia with a regular rhythm, normal s1 and s2, and without murmurs, rubs, or gallops. Initial laboratory workup reveals a hemoglobin of 5.5 g/dL, reduced from a baseline of 12 g/dL on routine outpatient laboratory testing from 3 months prior. His basic metabolic panel, arterial blood gas (ABG), and lactateare all within normal limits. A chest radiograph (CXR) is normal.

What is the mechanism of this man’s dyspnea on exertion?

A. Decreased cardiac output

B. Decreased oxygen delivery

C. Decreased systemic vascular resistance

D. High-output heart failure

E. Pulmonary edema

Answer:

A 59-year-old man with a history of hypertension and hyperlipidemia presents with 1 hour of substernal chest pressure

 A 59-year-old man with a history of hypertension and hyperlipidemia presents with 1 hour of substernal chest pressure rated an 8 on a scale of 1 to 10 with radiation down the left arm and associated with diaphoresis. Initial vital signs are notable for a blood pressure (BP) of 92/64 mmHg and a heart rate (HR) of 92 beats/min. His electrocardiogram (ECG) is shown below

What is the most likely diagnosis?

A. Anterior ST-elevation myocardial infarction

B. Inferior ST-elevation myocardial infarction

C. Pericarditis

D. ST changes not meeting specific ischemia criteria; additional ECGs should be obtained.

ANSWER: 

Approach to Patient Presenting with Numb toes - History and Examination

A middle aged man has developed numbness and tingling in his toes and feet, and more recently his fingertips. He also complains that he trips up more frequently.

Clinical Approach: This man has distal sensory symptoms and motor symptoms.  Here it is important to decide whether this is due to a peripheral cause ,  central or a combination of both.

Clinical History :
1. Is this an urgent case? Ask about the duration of symptoms and rate of progression.  Any worrying associated symptoms like loss of sphincter control or difficulty in breathing.

2. Differentiating between peripheral and central nervous system dysfunction:

A peripheral nervous system dysfunction is characterized by

• tingling, numbness and burning in feet.  
• Numb fingers. 
• Foot drop
• Difficulty in rising from a chair
• Difficulty in going up and down stairs.  

A spinal cord lesion is characterized by

• Legs and feet feeling stiff and heavy. 
• Clumsy stiff hands
• Sphincter disturbances. 

3. Duration of symptoms may help determine the cause of neuropathy.  

4. Any associated pain.

Past History: Ask specifically about:

• Diabetes mellitus 
• Alcohol intake 
• Current medications
• Dietary history 
• Pernicious anemia 
• Hypothyroidism 
• Weight loss 
• Smoking 
• Neck trauma 
• Rheumatoid arthritis. 

Clinical Examination: 

1. Signs in case of peripheral nervous system disorder 

• Distal weakness 
• Absent ankle reflexes
• Stocking distribution sensory loss
• Muscle wasting (if severe) 

2. Signs in case of central nervous system disorder 

• Spastic tone
• Weakness both proximal and dismally, but predominantly in leg flexor
• Brisk reflexes 
• Extensor plantars
• Possible sensory level 

3. Is is important to check if the signs are symmetrical?

• Asymmetry in the context of an upper motor neurone syndrome would represent a Brown-Sequard syndrome with loss of proprioception ispilateral to the weak leg, and loss of pain and temperature sensation contralateral to the weak leg. 
• Asymmetric lower motor neurone findings suggest mononeuritis multiplex or entrapment neuropathic..

4. Check for associated cranial nerve pansies

• Deafness in CN VIII
• Bilateral facial weakness in Guillain-Barre syndrome and Sarcoidosis 
• Malignant infiltration of the basal meninges may lead to multiple cranial nerve palsies. 

5. General Examination :

Look and check if the patient is systemically well? 

• Cachexia may suggest malignancy or alcoholism 
• Vasculitic rash in systemic vasculitis 
• Look for signs of hypothyroidism 
• Check 

Nausea And Weight Loss In A 45 Year old Alcoholic... Case Study

A 45 years old man consults his general practitioner (GP) with a 6-month history of reduced appetite
and a weight loss, from 78 to 71 kg. During the last 3 months he has had intermittent nausea, especially in the mornings, and in the last 3 months the morning nausea has been accompanied by vomiting on several occasions. For 1 month he has noted swelling of his ankles. Despite his weight loss he has recently noticed his trousers getting tighter. He has had no abdominal pain. He has no relevant past history and knows no family history as he was adopted.
He takes no medication. From the age of 18 he has smoked 5–6 cigarettes daily and drunk 15–20 units of alcohol per week. He has been a chef all his working life, without exception in fashionable restaurants. He now lives alone as his wife left him 1 year ago.

Examination
He has plethoric features. There is pitting oedema of his ankles. He appears to have lost weight from his limbs, but not his trunk. He has nine spider naevi on his upper trunk.
His pulse is normal, and the rate is 92/min. His jugular venous pressure (JVP) is not raised, and his blood pressure is 146/84 mmHg.
The cardiovascular and respiratory systems are normal.
The abdomen is distended. He has no palpable masses, but there is shifting dullness and a fluid thrill

Investigations: 
Haemoglobin = 12.6 g/dL (normal = 13.3–17.7 g/dL)
White cell count = 10.2 × 109/L (normal = 3.9–10.6 × 109/L)
Platelets = 121 × 109/L (normal = 150–440 × 109/L)
Sodium = 131 mmol/L (normal = 135–145 mmol/L)
Potassium = 4.2 mmol/L(normal = 3.5–5.0 mmol/L)
Urea = 2.2 mmol/L (normal = 2.5–6.7 mmol/L)
Creatinine  = 101 μmol/L (normal = 70–120 μmol/L)
Total protein = 48 g/L (normal = 60–80 g/L)
Albumin = 26 g/L (normal = 35–50 g/L)
Bilirubin =  25 mmol/L (normal = 3–17 mmol/L)
Alanine transaminase = 276 IU/L (normal = 5–35 IU/L)
Gamma-glutamyl transaminase = 873 IU/L (normal = 11–51 IU/L)
Alkaline phosphatase = 351 IU/L (normal = 30–300 IU/L)
International normalised ratio (INR) = 1.4 (normal = 0.9–1.2)

Urinalysis: no protein; no blood

• What is the diagnosis?
• How would you manage this patient?

Aortic Regurgitation - History, Examination And Study Questions & Answers

Clinical History
· Patients may be asymptomatic (but may have normal or depressed left ventricular function).

· Dyspnoea and fatigue (due to left ventricular impairment and low cardiac output initially on exertion).
· Symptoms of left ventricular failure in later stages.
· Angina pectoris is less common than in aortic stenosis; it usually indicates coronary artery disease.

Examination

1. Pulse
· Collapsing pulse (large volume, rapid fall with low diastolic pressure).
· Visible carotid pulsation in neck (dancing carotids or Corrigan's sign).

· Capillary pulsation in fingernails (Quincke's sign).
· A booming sound heard over femorals ('pistol-shot' femorals or Traube's sign).
· To and fro systolic and diastolic murmur produced by compression of femorals by stethoscope
(Duroziez's sign or murmur).

2. Heart
· Heart sounds are usually normal.
· Apex beat is displaced outwards and is forceful.
· Third heart sound (in early systole with bicuspid aortic valve).
· Early diastolic, high-pitched murmur is heard at the left sternal edge with the diaphragm - if not
readily apparent, it is important to sit the patient forward and auscultate with the patient's breath held
at the end of expiration. When the ascending aorta is dilated and displaced to the right, the murmur
may be heard along the right sternal border as well.
· An ejection systolic murmur may be heard at the base of the heart in severe aortic regurgitation
(without aortic stenosis). This murmur may be as loud as grade 5 or 6, and underlying organic stenosis can be ruled out only by investigations.
· Ejection click suggests underlying bicuspid aortic valve.
· Mid-diastolic murmur of Austin Flint may be heard at the apex. It is typically low-pitched, similar to the murmur of mitral stenosis but without a preceding opening snap.
· Loud pulmonary component of second sound (suggests pulmonary hypertension).

3. General examination
· Head nodding in time with the heart beat (de Musset's sign) may be present.
· Visible carotid pulsation may be obvious in the neck - dancing carotids or Corrigan's sign.
· Check the blood pressure (wide pulse pressure).
· Look for systolic pulsations of the uvula (Muller's sign).
· Check pupils for Argyll Robertson pupil of syphilis.
· Look for stigmata of Marfan's syndrome - high arched palate, arm span greater than height.
· Check joints for ankylosing spondylitis and rheumatoid arthritis.

QUESTIONS

A 24-year-old woman has acute renal failure following postpartum hemorrhage...

A 24-year-old woman has acute renal failure following postpartum hemorrhage. Laboratory studies showed
serum glucose, 150 mg/dL;
sodium, 135 mEq/L;
potassium, 6.5 mEq/L;
chloride, 105 mEq/L; and
bicarbonate, 15 mEq/L.
Therapy should include which of the following?
(A) Decrease potassium chloride to 10 mEq/L
(B) Intravenous 0.9% sodium chloride
(C) 100 mL of 50% glucose water with 10 U insulin
(D) Intravenous calcitonin
(E) Intravenous magnesium sulfate

Answer:

Elevated blood pressure in the setting of acute ischemic stroke needs to be judiciously treated because:

Elevated blood pressure in the setting of acute ischemic stroke needs to be judiciously treated because:

A. High blood pressure needs to be treated aggressively in order to decrease the incidence of intracranial bleeding.
B. Acute elevations in blood pressure usually do not spontaneously decline.
C. Blood pressures above 160 mmHg systolic or 100 mmHg diastolic are immediately life-threatening.
D. Areas of ischemic brain lose autoregulation and may be dependent on elevated mean arterial pressure to maintain perfusion.
E. Aggressive lowering of blood pressure with acute ischemic stroke improves outcome.

Answer :

A 66 year old woman presents with a history of weight loss - Case Study

History
A 66-year-old woman, a retired nurse, consults her general practitioner (GP) with a 4-month history of tiredness, slight breathlessness on exertion and loss of weight from 71 to 65 kg. Her appetite is unchanged and normal; she has no nausea or vomiting, but over the last 2 months she has had an altered bowel habit with constipation alternating with her usual and normal pattern. She has not seen any blood in her feces and has had no abdominal pain. She has had no post-menopausal bleeding. There is no relevant past or family history, and she is on no medication.
She has smoked 20 cigarettes daily for 48 years and drinks 20–28 units of alcohol a week.

Examination
She has slight pallor but otherwise looks well. No lymphadenopathy is detected, and her breasts, thyroid, heart, chest and abdomen, including rectal examination, are all normal.
The blood pressure is 148/90 mmHg.

Investigations: 

• Haemoglobin = 10.1 g/dL (normal = 11.7–15.7 g/dL)
• Mean corpuscular volume (MCV) = 76 fL (normal = 80–99 fL)
• White cell count = 4.9 × 109/L (normal = 3.5–11.0 × 109/L)
• Platelets = 277 × 109/L  (normal = 150–440 × 109/L)
• Sodium = 142 mmol/L  (normal = 135–145 mmol/L)
• Potassium = 4.4 mmol/L  (normal = 3.5–5.0 mmol/L)
• Urea  = 5.2 mmol/L  (normal = 2.5–6.7 mmol/L)
• Creatinine = 106 μmol/L  (normal = 70–120 μmol/L)
• Urinalysis: no protein, no blood
• Blood film shows a microcytic hypochromic picture.

Questions

• What is the most likely diagnosis?

• How would you investigate the patient?

Case Discussion:

Transient Ischemic Attack

A 72-year-old woman with a past history of treated hypertension presents for review. Yesterday she had a 2 hour episode where she couldn't find the right word when speaking. This has never happened before and there were no associated features. Neurological examination is unremarkable and blood pressure was 150/100 mmHg. Her only current medication is amlodipine.

What is the most appropriate management?
A. Aspirin 300 mg immediately + specialist review within 2 weeks
B. Specialist review within 2 weeks
C. Aspirin 300 mg immediately + specialist review within 24 hours
D. Aspirin 75 mg + outpatient CT brain
E. Specialist review within 24 hours

Answer:

Haemochromatosis - Quick Case Discussion

Haemochromatosis
This 52‐year‐old man was referred after a diagnosis of diabetes mellitus was made by his GP. Please
examine him and discuss further investigations.

Clinical signs
• Increased skin pigmentation (slate‐grey colour)
• Stigmata of chronic liver disease
• Hepatomegaly

Scars of
• Venesection
• Liver biopsy
• Joint replacement
• Abdominal rooftop incision (hemihepatectomy for hepatocellular carcinoma)

Evidence of complications
• Endocrine: ‘bronze diabetes’ (e.g. injection sites), hypogonadism and testicular atrophy
• Cardiac: congestive cardiac failure
• Joints: arthropathy (pseudo‐gout)

Discussion

Melanosis coli

A 23-year-old female with a history of diarrhoea and weight loss has a colonoscopy to investigate her symptoms.
A biopsy is taken and reported as follows: Pigment laden macrophages suggestive of melanosis coli

What is the most likely diagnosis?
A. Intestinal melanoma
B. Haemochromatosis
C. Ulcerative colitis
D. Laxative abuse
E. Colorectal cancer

Answer:

Eisenmenger’s syndrome - Questions & Answers For A Long Case

Eisenmenger syndrome refers to any untreated congenital cardiac defect with intracardiac communication that leads to pulmonary hypertension, reversal of flow, and cyanosis. The previous left-to-right shunt is converted into a right-to-left shunt secondary to elevated pulmonary artery pressures and associated pulmonary vascular disease.

What are your differential diagnoses?

 As follows:

• Congestive cardiac failure
• Chronic cor pulmonale.

Q. What investigations would you suggest ?

 As follows:

1. X-ray chest (enlargement of central pulmonary arteries with peripheral pruning of pulmonary vessels).

2. ECG (RVH, RAH, right axis deviation).

3. Echocardiography.

Q. What are the clinical features of Eisenmenger’s syndrome?

As follows:

• Dyspnea
• Fatigue
• Syncope
• Angina
• Hemoptysis
• Features of CCF.

On examination:

• Central cyanosis (not corrected by giving 100% oxygen. Differential cyanosis (cyanosis in toes, not in the hand) occurs in PDA.
• Clubbing (differential clubbing—clubbing in toes, not in the hand, occurs in PDA).
• Pulse—low volume.
• Prominent “a” wave in JVP.
• Other signs of pulmonary hypertension – palpable P2, left parasternal lift, epigastric pulsation due to RVH. Ejection click and ejection systolic murmur may be present.
• Tricuspic regurgitation may occur (in such case, prominent V wave in JVP, also there may be a pansystolic murmur in left lower parasternal area).
• Polycythemia.
• Original murmur of VSD, ASD or PDA—decrease in intensity, even may disappear.

Regarding Atypical Mycobacteria Affecting a Patient With Bronchiectasis...

A 68-yr-old man with bronchiectasis is found to have Acid fast bacilli in his sputum. The microbiology report suggests this may be an opportunistic or atypical mycobacterium.

Which of the following is the least likely infectious agent?
A) Mycobacterium kansasii
B) Mycobacterium malmoense
C) Mycobacterium xenopi
D) Mycobacterium leprae
E) Mycobacterium avium intracellulare


Answer:

Myocardial Infarction: Secondary Prevention

A 55-year-old man is admitted following an anterior myocardial infarction. Which of the following drugs is least likely to reduce mortality in the long-term?
A. Atorvastatin
B. Atenolol
C. Ramipril
D. Aspirin
E. Isosorbide mononitrate

Answer:

Chronic liver disease and hepatomegaly (A Case For MRCP PACES)

This man complains of weight loss and abdominal discomfort. His GP has referred him to you for a
further opinion. Please examine his abdomen.

Clinical signs
Signs of chronic liver disease
• General: cachexia, icterus (also in acute), excoriation and bruising
• Hands: leuconychia, clubbing, Dupuytren’s contractures and palmar erythema
• Face: xanthelasma, parotid swelling and fetor hepaticus
• Chest and abdomen: spider naevi and caput medusa, reduced body hair,
gynaecomastia and testicular atrophy (in males)

Signs of hepatomegaly
• Palpation and percussion:
⚬⚬ Mass in the right upper quadrant that moves with respiration, that you are not able to get above and is dull to percussion
⚬⚬ Estimate size (finger breadths below the diaphragm)
⚬⚬ Smooth or craggy/nodular (malignancy/cirrhosis)
⚬⚬ Pulsatile (TR in CCF)
• Auscultation
⚬⚬ Bruit over liver (hepatocellular carcinoma)

Evidence of an underlying cause of hepatomegaly
• Tattoos and needle marks  - Infectious hepatitis
• Slate‐grey pigmentation  - Haemochromatosis
• Cachexia - Malignancy
• Mid‐line sternotomy scar -  CCF

Evidence of treatment
• Ascitic drain/tap sites
• Surgical scars

Evidence of decompensation
• Ascites: shifting dullness
• Asterixis: ‘liver flap’
• Altered consciousness: encephalopathy

Discussion

Venous Thromboembolism: Risk factors

Which one of the following statements regarding the etiology of venous thromboembolism (VTE) is correct?
A. Third generation combined oral contraceptive pills are safer than second generation ones
B. VTE develops in around 5% of patients with rheumatoid arthritis
C. Female gender is a risk factor recurrent VTE
D. The second trimester of pregnancy is associated with a greater risk than the puerperium
E. Tamoxifen therapy increases the risk of VTE

Answer:

A 44-year-old male presents to the emergency room with an acutely swollen right knee

A 44-year-old male presents to the emergency room with an acutely swollen right knee. He has been in good health, and he has no chronic health conditions and no history of trauma. 

The most important evaluation should be:
A. MRI of the knee
B. Erythrocyte sedimentation rate
C. Diagnostic arthrocentesis of the knee
D. Complete blood count
E. Rheumatoid factor

Answer:

A 26 Year Old Woman presents To Her General Physician With Persistent Cough

A 26-year-old teacher has consulted her general practitioner (GP) for her persistent cough. She wants to have a second course of antibiotics because an initial course of amoxicillin made no difference. The cough has troubled her for 3 months, since she moved to a new school. The cough is now disturbing her sleep and making her tired during the day. She teaches games, and the cough is troublesome when going out to the playground and when jogging.
In her medical history she had her appendix removed 3 years ago. She had her tonsils removed as a child and was said to have recurrent episodes of bronchitis between the ages of 3 and 6 years.
She has never smoked and takes no medication other than an oral contraceptive. Her parents are alive, and well and she has two brothers, one of whom has hay fever.

On Examination
The respiratory rate is 18/min. Her chest is clear, and there are no abnormalities in the nose or pharynx or the cardiovascular, respiratory or nervous systems.

Investigations:
• Chest X-ray is reported as normal.
• Spirometry is carried out at the clinic, and she is asked to record her peak flow rate at home, the best of three readings every morning and every evening for 2 weeks. Spirometry results are as follows:
FEV1 (L) = 3.9   ( predicted = 3.6–4.2)
FVC (L) = 5.0     ( predicted =  4.5–5.4)
FER (FEV1/FVC) (%) = 78   ( predicted = 75–80)
PEF (L/min)  =  470   ( predicted = 440–540)

Peak flow recording at home showed diurnal variations.

Questions
• What is your interpretation of these findings?
• What do you think is the likely diagnosis, and what would be appropriate treatment?

Answers and Case Discussion:

A 16-Year-Old Girl With a Rash and Shortness of Breath - An Interesting Case Study

Clinical History: 
A 16-year-old girl presents to the emergency department with generalized pruritus, eye swelling, a full-body rash, and shortness of breath after playing basketball at school. She reports that she was playing basketball with her friends when she first noticed itchy palms. She stopped playing and washed her hands. The itch worsened and was followed by a rash and shortness of breath. She also felt that her throat was tightening, and she had difficulty swallowing. She was taken to the school nurse, paramedics were called, and she was brought to the local emergency department.

The patient has had several similar episodes within the past year and feels that the episodes are getting worse. The first episode occurred about 1 year ago while playing volleyball in a hot gym. She developed itchy palms and stopped to go drink some water; the itchiness went away without any medical attention. Recently, the episodes have been occurring more frequently and are more severe. Some episodes are associated with even mild physical exertion, especially when the temperature outside is hot. When she stops the physical activity, the symptoms typically go away. She cannot recall eating any specific foods that are related to her episodes. She is not taking any medications, vitamins, or herbal supplements.

The patient is otherwise healthy, with no significant medical history. She denies any malaise, fatigue, weight loss, nausea, vomiting, fever, or joint pain. She is in the 11th grade and does well in school, getting mostly A's and only a few B's. She wants to go to college. She has many friends at school. She enjoys biking, dancing, and texting. Occasionally, dancing causes her to feel itchy, but she just "takes a break," and the itch goes away.

Physical Examination and Workup

Upon physical examination, the patient is a well-nourished, well-developed teen in mild respiratory distress. Her temperature is 98.6o F, respiratory rate is 30 breaths/min, heart rate is 110 beats/min, and blood pressure is 100/60 mm Hg. Periorbital angioedema and facial erythema are noted. Extraocular eye movements are within normal limits. Her nasal cavity shows normal nasal mucosa, septum, and turbinates bilaterally.