1. TUTORIAL MED - II 28/04/2016

2. A 63 year old gentleman presents with three month history of difficulty in swallowing. The esophageal manometry showed increased pressure and sphincter fails to relax on with swallowing. After swallowing there are no progressive peristaltic contractions with all contractions occurring simultaneously. 1. Describe 2 abnormal findings of the image shown? a. Dilated upper esophegous b. Narrowed lower esophagous 2. What is the most likely diagnosis? a. Achalasia

3. 60 year old known case of hypertension noticed weakness of hands and feet slowly progressing over years. O/E wasting of tongue and muscles of hand and feet with fasciculation. Sensations all normal The planter response up-going bilaterally. 1.What is the likely diagnosis? Amylotrophic lateral sclerosis type of MND 2.What other essential investigation is recommended? EMG and nerve conduction study

4. This patient presented with sore throat, fever and migratory arthritis 1.Describe the skin lesion? a.Erythema marginatum or Erthema anular 2.What is its significance in rheumatic fever? One of the major criteria 3.What serological test is diagnostic importance? a.ASO - titer

5. This man a known case of Diabetes mellitus presented with retrosternal chest pain and vomited twice on his way to emergency department. 1.Describe 2 ECG findings of clinical importance? a.ST elevation in lead I,V2,V5,V6 b.Q wave or failure of R wave progression in V4 V5 2.What is the likely diagnosis a.Anterolateral MI b.Pericarditis

6. 1.Describe the abnormal ECG finding? Irregular heart rate 2. What is the diagnosis? Atrial fibrillation

7. Describe 2 abnormal CT findings? Hypodense area in frontal lobe, cross the suture line Obliteration of ventricle Shift to the opposite side Edema 2.What is the diagnosis? a. Subdural hematoma An 89 year old woman presents to your Emergency Department with a two week history of several falls and new right sided weakness.

8. 46 year old man presented six month history of with Fatigue, Fever on and off, joint pains and weight loss of 5 Kg. O/E Tender maculopapular rash on his shins & cervical lymphadnopathy. Investigations: CBC: Hb 14.6 g/dl WBC4.7 X 10 /dl U/E’s Sodium136 mmol/l Potassium 4.2 mmol/ Calcium3.4 mmol/l 1.What is the likely cause of rash on shins? a.Erythema nodosum 2.Name 2 most likely diagnoses? a.Sarcoidosis b.TB

9. 32 year female presented with fever & weight loss 1.Describe radiological findings? Shoaws miliary nodes 2.List two conditions of differential diagnosis? a.Miliary TB b.Metastasis

10. 28 year old female in her normal state of health presented with acute painful swelling of the back of his right leg. She has been on contraceptive pills for six months. 1.What is the likely diagnosis? a.DVT b.Ruptured baker cyst 2.What 2 steps are advised to confirm diagnosis? a.D-D imer b.Spiral ct c.Doppler US for legs and pelvis

11. This patient has long history of alcohol abuse. 1.What is the typical feature of the lesion shown? a.Spider nevi / angioma 2.What organ disease is this lesion commonly associated with a.Liver

12. This patient experienced recurrent episodes of pallor followed by bluish discoloration fingers and hand hands on exposure to cold. 1.What is the clinical diagnosis? a.Raynaud phenomena b.Scleroderma 2.What is the cause of this phenomena? a.vasospasms b.Cold expousre

13. 76 year old man had an episode of bilateral loss of vision lasting for 5 minutes. He had similar episode 2 days earlier. On each occasion the vision was lost rapidly. He had been lethargic for several weeks and had pain in his jaw on chewing. His blood tests are as follows: Hb14.2 g/dl MCV81 fl Plt212 x 10 9 /l WBC10.2 x 10 9 /l ESR132mm/h What is the likely diagnosis? a.Giant cell arteritis, polymalgia What treatment would you prescribe? a.Pulse therapy of steroids

14. A 47 year old woman complains of generalized tiredness, low mood, altered bowel habits and more recently generalized itching. O/E she is jaundiced and has 4 cm hepatomegaly and xanthelasma of her eyes. Her liver function tests include: Total bilirubin60 µmol/l AST35 IU/l ALT 34 IU/l ALP180 U/l GGT90 U/l Albumin39 g/l AMA titer 1:140 1.Describe 2 lab abnormalities? a.ALT b.GGT 2.Suggest the diagnosis? a.Primary biliary cirrhrosis b.Scleroderma cholngitis

15. A 20 year old man known case of sickle cell disease developed nocturia and swollen ankles. The following blood results were obtained: Plasma urea8.0 mmol/l Sodium145 mmol/l Potassium4.0 mmol/l Bicarbonate 22 mmol/l Phosphate0.9 mmol/l Serum Albumin21 g/l (NR: 35-50 g/L) 24 hour urinary protein10 g Early morning urine osmolality310 mOsm/kg (NR: 500-800 mOsm/kg of water) 1.What is the clinical diagnosis? a.Nephrotic syndrome 2.What is the commonest renal complication of SCD a.Renal papillary necrosis b.Infection

16. In Type 2 respiratory failure blood gas analysis reveals? A.Hypoxia and hypercapnea B.Hypoxia and hypocapnea C.Normal PO 2 and decreased PCO 2 D.Increased PO 2 and increased PCO 2 In acute severe asthmatic attack? A.Initiate use of oral steroids therapy B.Oxygen as the first line treatment C.Avoid ipratropium bromide inhalation D. Initiate inhaled bronchodilator therapy Acute lung injury (ARDS) should be differentiated from? A.Congestive cardiac failure B.Spontaneous pneumothorax C.Acute LVF D.Acute asthma

17. Lung function tests in restrictive defect may reveal? A.Very low FEV1/ FVC ratio B.Increased lung volume C.Decrease in FVC D.Very low DLCO Etiological factors of acute pancreatitis include? A.Addison’s disease B.Hypothyroidism C.Alcohol abuse D.Hypopituitarism Recognized complications of hemodialysis include? A.Hypotension B.Hyperpigmentation C.Hyperlipidemia D.Congestive cardiac failure

18. Spastic paraplegia is a recognized feature of? A.Guillain Barré syndrome B.Hypokalemic periodic paralyses C.Parasagittal cortical syndrome D.Spinal muscular atrophy Intermittent bulbar palsy is seen in? A.Snake bite B.Rabies C.Myasthenia gravis D.Poliomyelitis Myopathy is best diagnosed by? A.Muscle enzyme study B.Nerve conduction study C.Electromyography D.Muscle biopsy

19. Onset of symptoms with continuous worsening course of MS occurs in? A.Relapsing-remitting. B.Secondary-progressive. C.Primary-progressive. D.Progressive-relapsing The classical clinical sign in progressive bulbar palsy is? A.Tongue spasticity B.Brisk jaw reflex. C.Emotional liability. D.Tongue fasciculation. Motor neurone disease typically presents with? A.Bladder and bowel incontinence B.Pseudo hypertrophy of calf muscles C.Amyotrophic lateral sclerosis D.Demyelinating polyneuropathy

20. Serum vitamin B12 level is increased in? A.Pernicious anemia B.Di Guglielmo’s syndrome C.Chronic myeloid anemia D.Acute lymphocytic leukemia Initiation of chemotherapy in CLL is indicated for? A.Poor appetite with steady weight B.Extreme fatigue C.Age 60 years D.Fever with night sweats A patient with acromegaly may have? A.Increased libido B.Decreased risk for coronary artery disease C.Bi-nasal hemianopia D.Increased level of Insulin-like growth factor 1(IGF 1)