A Special Conversation

A 51 year old male, a smoker and alcoholic presented with scrotal swelling, lower limb swelling, abdominal distension, cough and shortness of breath

  1. What differentiates an alcoholic from someone who drinks alcohol regularly?
  2. You say that this person denied symptoms of renal impairment like hematuria and proteinuria. Why do you say that?
  3. What exactly do you mean when you say that you are unsure of the viral status in the family?
  4. This person has tattoos on the left arm. What are the risks associated with tattoos?
  5. What are parameters you looked into when you wrote: there was no peripheral neuropathy?
  6. What is the significance of an enlarged spleen in this person?
  7. What is the ultrasound evidence of cirrhosis liver?
  8. Why was Thiamine given to this patient in the hospital?
  9. When this patient developed abdominal pain, he was treated for spontaneous bacterial peritonitis. Why is that?
  10. Why did this patient abscond from the ward?

A 52 year old man who presented with acute epigastric pain, sweating and dizzyness. He was later diagnosed to have inferior wall, post wall and right ventricular myocardial infarction

  1. Explain why he may have had a BP of 82/49mm Hg and a pulse rate of 45/min on presentation.
  2. Explain how the myocardial infarction was judged to be in the 3 different areas described above.
  3. Why should you be worried when you hear that norepinephrine was given to this patient because of the low BP?
  4. What is the significance of the observation that the ST segment reduced by 50 percent after streptokinase?
  5. What is a cardiac rehabilitation program?
  6. Why was this patient planned for an exercise stress test?
  7. Was it right to prescribe this patient Atorvastatin 20mg ON when his serum ALT was 401U/L at the time of discharge?

A 49 year old man with COPD and chronic Hepatitis C infection presented with shortness of breath, cough, sputum, pleuritic chest pain and fever

  1. What significance do you give to the information that he had lost 3 kg of weight in the past two months?
  2. What parameters did you use to say that he has a barrel-shaped chest?
  3. You noticed that he was using accessory muscles of respiration. What are these muscles?
  4. What significance do you attach to the palmar erythema that you noticed?
  5. Your respiratory findings were: dull percussion note in R mid zone, decreased tactile fremitus and coarse crepitations in that area, along with generalised rhonchi. What do these findings suggest?
  6. He had a Mantoux test and sputum AFB examination done. What was the reason for suspecting tuberculosis in him?
  7. What is the significance of a pneumonia that does not resolve as expected?

A 55 year old man with CKD, HPT, and DM who presented with bilateral lower limb swelling

  1. Why do you say: he denied periorbital swelling?
  2. He had shortness of breath on exertion. What could be the reasons?
  3. His serum K was low in spite of an elevated serum creatinine. Furthermore his serum bicarbonate was high. Explain why this may have happened.
  4. You are awaiting his serum 24 hour protein result. What decisions will you make based on this?
  5. His ECG showed sinus bradycardia. Give reasons for this.
  6. What does the combination of low serum K and high blood pressure suggest to you?

A 13 year old girl with fever and bilateral ankle pain

  1. She had migratory polyarthritis and was diagnosed as acute rheumatic fever. What are the criteria for the diagnosis of rheumatic fever?
  2. She had a new onset pansystolic murmur. What does this suggest?
  3. ECG did not show prolonged PR interval. What is the significance?
  4. Why was anti-streptolysin O antibodies tested for her?
  5. Why was she given benzylpenicillin and gentamycin initially?
  6. Why was she prescribed IM Benzathine penicillin at discharge?
  7. Why was she treated with prednisolone?
  8. What is the difference between rheumatic heart disease and rheumatic fever?

Discuss the various possibilities inherent in the following presentations

1. A 59 year old man with DM, chronic venous insufficiency and chronic liver disease who presented with lower limb swelling, abdominal distension and shortness of breath

2. A 73 year old man with hypertension, COPD who presented with hemoptysis and shortness of breath. He was later diagnosed to have a renal cell carcinoma. He received transexamic acid as part of his treatment

3. A 37 year old man, an ex-intravenous drug abuser who had been treated for pulmonary tuberculosis, now presented with cough, hemoptysis, and fever of one month duration. During his hospital stay he was noted to have elevated prothrombin time, elevated partial thromboplastin time and reduced platelets

4. A 67 year old woman with diabetes and hypertension who developed atrial fibrillation and was treated with amiodarone and digoxin

5. A 60 year old man with HPT, DM and chronic Hepatitis B infection who had a history of hematemesis and presented with abdominal distension, leg swelling and tea-coloured urine. His blood counts showed a low hemoglobin with macrocytosis

6. A 41 year old man with DM and HPT who developed an acute inferior wall STEMI and subsequently developed hypotension and bradycardia and acute kidney injury after receiving streptokinase. Post discharge, his exercise stress test was reported as inconclusive

7. A 54 year old woman with DM and HPT who had headache and right sided body weakness. Her CT brain showed hypodense lesions in the R cerebellum and in the left thallamus

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