1. Quick Questions
a. Two people complain of pain abdomen - in one, the pain is due to peritonitis and in the other, the pain is due to ureteric colic. What will be the difference in the way these two people respond to the pain?
b. Can the ESR be elevated without inflammation? Can it be normal in spite of inflammation?
c. What clue in the peripheral blood may explain why a woman has new onset of increased menstrual bleeding?
d. What condition(s) should you think of when you find fragmented red cells in the blood?
e. Both direct and indirect Coomb's test detect antibodies against red cells. What is the difference?

2. Chronic cough
A 22 years old Chinese gentleman, fresh university graduate with no known medical illness, presented with prolonged productive cough with whitish sputum for 4 weeks and fever for 3 weeks. He also had weight loss of 8 kg in one month time and occasional night sweats. On examination, he appeared lethargic and cachexic with temperature of 37 degrees C. There was reduced chest expansion, presence of stony dullness on percussion, reduced breath sound and vocal resonance over the left lower zone of the lung upon examination of the respiratory system.
Full blood count, renal profile, liver function test were normal. Mantoux test reading was 18 mm and quantiferon TB gold test was positive. Chest X-ray showed left fibrotic lesion on upper zone and pleural effusion of the left lung. Pleural fluid was exudative. Ultrasound of left hemithorax revealed left complex pleural effusion with multiple septations and CECT thorax revealed bilateral upper zone fibrotic changes.

a. What diagnosis do the physical findings of the respiratory system suggest?
b. Is the Quantiferon TB gold test better than the Mantoux test for diagnosis of tuberculosis?
c. How do you recognise an opacity in the lung as being due to fibrosis on the chest x-ray?
d. What is the significance of "multiple septations" in pleural effusion?

3. Limb weakness
A 62-year- old Malay man, chronic ex-smoker with underlying hypertension, type II diabetes mellitus and dyslipidemia for the past 8 years was brought in due to left-sided body weakness. It was of sudden onset and associated with profuse sweating followed by loss of consciousness for approximately 10 minutes. He did not have headache, dyspnoea, chest pain, fever or any signs suggestive of seizures. Prior the episode, he had been experiencing dizziness on awakening and blurring of vision.

His current list of medications included tablet perindopril 8 mg OD, tablet amlodipine 10 mg OD, tablet metformin/glibenclamide 500 mg/5 mg BD, subcutaneous (s/c) insulatard basal 10 units ON, tablet simvastatin 20 mg ON and tablet aspirin 100 mg OD.

On examination, he was well built was lying supine on the bed. He was drowsy with Glasgow coma scale (GCS) of 11/15 (E3V2M6). Left-sided facial asymmetry with drooping of the edge of the mouth towards the left side and slurring of speech were noted. He was hypertensive with blood pressure (BP) of 174/90 mmHg and was hyperglycemic with capillary blood glucose measuring 10.2 mmol/L. Physical examination further revealed flaccid muscle tone and reduced power of both upper and lower limbs over the left side, with Medical Research Council (MRC) grade of 2/5. Extensor plantar response was positive on the left side.

On day 3 of admission, neurological examination showed rigid muscle tones with MRC of 3/5 and brisk reflexes over the left upper and lower limbs. On day 5 of admission, he complained of neck pain and there was presence of neck stiffness on examination.

  1. What is the reason for his limb weakness on the left side of the body?
  2. What does the loss of consciousness at the onset of his illness suggest?
  3. What does the student mean when he says the patient "did not have signs suggestive of seizures"?
  4. How do you differentiate UMN type of facial weakness from LMN type of facial weakness in a patient with stroke? What is the clinical implication of knowing this?
  5. Is "slurring of speech" the same as dysphasia?
  6. What must you suspect when a patient presents with this kind of illness and has neck stiffness on examination?

4. Managing diabetes in the above patient after admission

  1. Will you continue his usual diabetes medicines after admission?
  2. What will be your strategy to control his blood sugar in the first 24 hours
  3. Assuming that his FBS is 8.6mmol/L on Day 2 after admission, what will you do?
  4. What medication will you advice him for diabetes at discharge?
  5. If, on review 3 months later, his FBS is 6mmol/L and his HbA1c is 8 percent, what will you do?

5. Making the diagnosis of a disease you have never seen before
a. You have a middle aged patient with chronic cough and opacities in the chest x-ray which turn out to be granulomas.
b. Then you detect that the patient has nasal polyps and oral ulcerations.
c. After that, you realise that the patient has recently been diagnosed with episcleritis and mononeuritis multiplex.
d. So you think of a disease, do a test and find that the blood of this patient tests positive for ANCA (anti neutrophil cytoplasmic antibodies)

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