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For discussion with final year medical students (March to July 2015)

A. Student initiated discussions Weeks 1 and 2
B. Student initiated discussions Weeks 3 and 4
C. Questions and Answers - March 2015
D. Student initiated discussions - Group A


April 2015
PORTFOLIO REVIEW AND QUESTIONS


8
A 58 year old man presents with breathlessness. Two diagnoses are considered: COPD and Heart Failure. For each of the scenarios given below, choose which of these two diagnoses is more likely.

A. If you are told that he is a smoker and that, on auscultation of his lungs, vesicular breathing with crepitations at the bases of both lungs are heard, which of the following statements do you agree with as the cause of his breathlessness?

  1. Heart failure is much more likely than COPD
  2. Heart failure is slightly more likely than COPD
  3. Heart failure and COPD are both equally likely
  4. COPD is slightly more likely than Heart failure
  5. COPD is much more likely than Heart failure

B. If you are told that he has cardiomegaly and generalised rhonchi in his lungs, which of the following statements do you agree with as the cause of his breathlessness?

  1. Heart failure is much more likely than COPD
  2. Heart failure is slightly more likely than COPD
  3. Heart failure and COPD are both equally likely
  4. COPD is slightly more likely than Heart failure
  5. COPD is much more likely than Heart failure

C. If you are told that he has an audible systolic murmur at the cardiac apex and diminished air entry over the right lung, which of the following statements do you agree with as the cause of his breathlessness?

  1. Heart failure is much more likely than COPD
  2. Heart failure is slightly more likely than COPD
  3. Heart failure and COPD are both equally likely
  4. COPD is slightly more likely than Heart failure
  5. COPD is much more likely than Heart failure

D. If you are told that he has atrial fibrillation and generalised rhonchi in both lungs, which of the following statements do you agree with as the cause of his breathlessness?

  1. Heart failure is much more likely than COPD
  2. Heart failure is slightly more likely than COPD
  3. Heart failure and COPD are both equally likely
  4. COPD is slightly more likely than Heart failure
  5. COPD is much more likely than Heart failure

E. If you are told that his blood pressure is 170/96mm Hg and that he has no abnormal findings on auscultation of the chest, which of the following statements do you agree with as the cause of his breathlessness?

  1. Heart failure is much more likely than COPD
  2. Heart failure is slightly more likely than COPD
  3. Heart failure and COPD are both equally likely
  4. COPD is slightly more likely than Heart failure
  5. COPD is much more likely than Heart failure

F. If you are told that he has tachycardia, a gallop rhythm and rhonchi on auscultation of the lungs, which of the following statements do you agree with as the cause of his breathlessness?

  1. Heart failure is much more likely than COPD
  2. Heart failure is slightly more likely than COPD
  3. Heart failure and COPD are both equally likely
  4. COPD is slightly more likely than Heart failure
  5. COPD is much more likely than Heart failure

G. If you are told that his x-ray chest shows hyperinflation of lungs and his ECG shows frequent ventricular ectopic beats, which of the following statements do you agree with as the cause of his breathlessness?

  1. Heart failure is much more likely than COPD
  2. Heart failure is slightly more likely than COPD
  3. Heart failure and COPD are both equally likely
  4. COPD is slightly more likely than Heart failure
  5. COPD is much more likely than Heart failure

7. A 57 year old man presents with breathlessness for 3 days. Look at his clinical data and then answer the questions below:

  1. has epigastric pain and nausea.
  2. has cough with white sputum
  3. has been admitted in hospital a number of times because of high blood pressure.
  4. takes twice daily insulin.
  5. undergone repair of inguinal hernia, an appendectomy, cataract surgery and laser therapy for his eyes.
  6. used to smoke regularly but stopped the habit 2 years ago.
  7. pulse rate is 64/min and regular.
  8. BP is 214/100mm Hg.
  9. respiratory rate is 27/min
  10. SpO2 under oxygen is 100%
  11. temperature is normal.
  12. JVP is not raised. Examination of the heart is normal.
  13. Vesicular breathing with crepitations are heard in both lungs
  14. Abdominal examination is normal.
  15. No gross neurological deficit.
  16. Hemoglobin 7.8g/dL
  17. Urea high; Creatinine high; Sodium normal; Potassium normal;
  18. Chest x-ray shows cardiomegaly
  19. ECG shows sinus rhythm with no abnormalities
  20. ECHO shows dilated left and right atria with left ventricular ejection fraction of 65%
  21. Arterial blood gases show a picture of respiratory alkalosis.

Questions:
7.1 The epigastric pain and nausea in this patient is most likely related to:
a. The elevated blood pressure
b. The crepitations in the lungs
c. The high urea and creatinine
d. The cough and white sputum
e. The cardiomegaly
f. None of the above

7.2 The pulse rate of 64/min in this patient is most likely related to:
a. The elevated blood pressure
b. The crepitations in the lungs
c. The high urea and creatinine
d. The history of smoking
e. The cardiomegaly
f. None of the above

7.3The low haemoglobin value in this patient is most likely related to:
a. The elevated blood pressure
b. The crepitations in the lungs
c. The high urea and creatinine
d. The history of smoking
e. The epigastric pain and nausea
f. None of the above

7.4The respiratory alkalosis in this patient is most likely related to:
a. The elevated blood pressure
b. The crepitations in the lungs
c. The twice daily insulin injections
d. The history of smoking
e. The pulse rate of 64/min
f. None of the above

7.5The dilated atria on echocardiogram in this patient is most likely related to:
a. The elevated blood pressure
b. The ejection fraction of 65%
c. The high urea and creatinine
d. The pulse rate of 64/min
e. The twice daily insulin injections
f. None of the above


Dr Velayudhan Menon, MD
Clinical Associate Professor of Medicine
International Medical University, Malaysia

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