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3.Case
Case 12
A 66-year-old man comes into your clinic as a new patient. Seven years ago at a
work-related health screening, he was diagnosed with hypertension and hypercholesterolemia.
At that time, he saw a physician who prescribed a diuretic and
encouraged him to lose some weight and to diet and exercise. Since that time,
the patient has not sought medical attention. During the past 2 months, he has
been experiencing occasional headaches, which he attributes to increased stress
at work. He denies chest pain, shortness of breath, dyspnea on exertion, or
paroxysmal nocturnal dyspnea. He smokes one pack of cigarettes per day and has
done so since he was 15 years old. He typically drinks two glasses of wine with dinner.
On examination, the patient is obese, and you calculate his body mass index
(BMI) as 30 kg/m2. His blood pressure is 168/98 mm Hg in the right arm and
170/94 mm Hg in the left arm. His blood pressure did not change with changes
in position. His heart rate is 84 bpm. He has no thyromegaly or lymphadenopathy.
Funduscopic examination reveals narrowing of the arteries, arteriovenous nicking,
and flame-shaped hemorrhages with cotton wool exudates. Cardiac examination
reveals that his point of maximal impulse is displaced 2 cm left of the midclavicular
line. There is an S4 gallop. No murmurs are auscultated. Lung and abdomen
examinations are normal.
What is your diagnosis?
What are your next steps?
Ticket 13
Select the features of the examination of the bronchopulmonary system in the elderly and senile age.
2. MCQ
1.Which one of the following is not a feature of renal artery stenosis?
Hypertension responds well to drugs
Kidneys maybe asymmetrical
Atherosclerotic plaques are common
Serum creatinine may increase with ACE inhibitors
2.Renal vein thrombosis is/are caused by -
Nephrotic syndrome
Invasive renal cell carcinoma
Pregnancy
Dehydration
Trauma
3. All are true of Nephrotic syndrome, except -
RBC casts in urine b) Hypo-proteinemia
Oedema d) Hyperlipidemia
4. All of the following are decrease in Nephrotic syndrome except-
a) Ceruloplasmin
Fibrinogen d) Albumin
3.Case
CASE 13
A 56-year-old man comes to the ER complaining of chest discomfort. He describes
the discomfort as a severe, retrosternal pressure sensation that had awakened him
from sleep 3 hours earlier. He previously had been well but has a medical history of
hypercholesterolemia and a 40-pack-year history of smoking. On examination, he
appears uncomfortable and diaphoretic, with a heart rate of 116 bpm, blood pressure
of 166/102 mm Hg, respiratory rate of 22 breaths per minute, and oxygen saturation
of 96% on room air. Jugular venous pressure appears normal. Auscultation
of the chest reveals clear lung fields, a regular rhythm with an S4 gallop, and no
murmurs or rubs. A chest radiograph shows clear lungs and a normal cardiac
silhouette. The electrocardiogram (ECG) is shown ST-segment elevation. Elevated CK-MB isoenzyme (Creatine Phosphokinase)
_ What is the most likely diagnosis?
_ What is the next step in therapy?
Ticket 14
1.Make a investigation plan for pneumonia in the elderly and senile age.
2.MCQ
1 All of the following are uremic manifestation improve with dialysis except -
Metabolic acidosis
Osteodystrophy
Asterixis
Nausea,vommiting and anorexia
2.Microalbuminuria refers to urinary albumin excretion rate of -
a) 30-300mg/24 hour b) 400-600 mg/24 hour
700-900 mg/24 hour d) >1000 mg/24 hour
3. The body of a 65yo man who was treated for TB and bronchitis
was seen at autopsy. His legs were swollen and his liver showed
signs of a transudate fluid. What was the cause of the transudate?
a. Liver cirrhosis.
b. Alcoholic liver disease.
c. Cardiac failure.
d. Budd-chiari syndrome.
e. TB.
4. A 55yo man has had severe pain in the right hypochondrium for 24h. The
pain comes in waves and is accompanied by nausea. Nothing seems to relieve
the pain. He feels hot and sweaty but has normal temp. What is the most
appropriate next inv:
A.US Abdomen
b. ERCP
c. MRCP
d. Serum amylase
e. UGI endoscopy
3.Case
Case 14
CASE 25
A 56-year-old woman presents to her doctor’s office complaining of gradually progressive, nonpainful enlargement of the terminal joint on her left hand over a 9-month period. She has some stiffness with typing but not first thing in the morning. She also reports pain in her right knee, which occasionally “locks up.”
The right knee also hurts after long walks. On examination, her blood pressure is 130/85 mm Hg, heart rate 80 bpm, and weight 285 lb. Examination reveals only a nontender enlargement of her left distal interphalangeal (DIP) joint, and the right knee is noted to have crepitus and slightly decreased range of motion. There is no redness or swelling.
_ What is your next step?
_ What is the most likely diagnosis?
_ What is the best initial treatment?
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