1. By Dr. Zahoor 1

2. Question 1 1. What is the diagnosis? 2

3. Answer 1 1. Acute Anterior Myocardial Infarction (deep Q waves, elevated ST segments and T wave inversion are seen in V1 – V5) 3

4. Question 2 4 This is the ECG of 55 year old who is drowsy and confused. 1.What abnormalities are present? 2.What is the diagnosis?

5. Answer 2 1. Bradycardia heart rate of 30/min - Absent P-wave - Tall T wave 2. Hyperkalemia 5

6. Question 3 A woman of 50 with nausea and anorexia. Calcium 1.63 mmol/L (N 2.25 – 2.62 mmol/L) Phosphate 2.50 mmol/L (N 0.8 – 1.4 mmol/L) Urate 0.88 mmol/L (N 0.21 – 0.37 mmol/L) 1. What is the diagnosis? 6

7. Answer 3 1. Chronic renal failure High urate and phosphate are due to glomerular failure Hypocalcaemia is common in renal failure cause may be failure of conversion of vitamin D 7

8. Question 4 A 35 year old man complains of weight loss and abdominal distention. Three years ago he was treated successfully for an itchy vesicular rash on his buttocks. Hemoglobin 8.3 g/dl MCHC 31 g/dl (N 32 – 36 g/dl) MCV 96fl (N 76 – 98 fl) Blood film : macrocytosis+ microcytosis+ anisocytosis+ poikilocytosis+ 1. What is the diagnosis? 2. What investigation will confirm the diagnosis? 3. What was the rash? 8

9. Answer 4 1. Coeliac Disease He has mixed macrocytic and microcytic anaemia suggesting iron and Folate (possibly B12 deficiency) 2. Jejunal biopsy 3. Dermatitis Herpetiformis (itchy vesicular rash is associated with celiac) 9

10. Question 5 A 25 year old Asian is admitted with headache and neck stiffness. He has been on no treatment. CSF findings: Pressure 24 cm water RBC 0 WBC 275 × 10 6 (275/mm 3 ) Lymphocyte 8o% Monocyte 10% Neutrophils 10% Protein 0.8 g/L (N 0.15 – 0.4 g/l) Glucose 1.8 mmol/L (N 3.3 – 5 mmol/L) Blood Glucose 5.7 mmol/L 1. What is the diagnosis? 10

11. Answer 5 1. Tuberculous Meningitis 11

12. Question 6 A man of 55 collapses outside a restaurant. He is on no drug therapy: 1. What is the underlying endocrine abnormality? 2. What test you will do to confirm the diagnosis? 12 Na115 mmol/L (N 133 – 145 mmol/L) K4.2 mmol/L (N 3.5 – 5 mmol/L) Urea1.8 mmol/L (3.3 – 7 mmol/L) Total protein52 g/L

13. Answer 6 1. Inappropriate ADH secretion 2. Plasma and Urine Osmolality In inappropriate ADH secretion plasma Osmolality is low and urinary Osmolality is high 13

14. Question 7 An obese 56 year old woman complains of daytime somnolence. Her husband says that she snores loudly. Investigations showed: Arterial blood (breathing air): PO2 10.4 kPa (78 mmHg) PCO2 5.6 kPa (43 mmHg) 1. What is the most likely diagnosis? 2. How can this diagnosis be confirmed? 14

15. Answer 7 1. Sleep apnea 2. Polysomnography 15

16. Question 8 A woman with Vitiligo became anemic. MCV 120 fl. 1. What is the diagnosis? 16

17. Answer 8 1. Pernicious anemia (due to anti bodies to intrinsic factor) 17

18. Question 9 A 60 year old man admitted for a hernia repair is found to have 1. What metabolic derangement is present? 2. Give two possible causes. 18 Plasma sodium144 Potassium2.9 Bicarbonate35 mmol/L Blood urea5.5 mmol/L

19. Answer 9 1. Hypokalemic alkalosis with normal renal function 2. Long term diuretic therapy Corticosteroid therapy Conn’s syndrome 19

20. Question 10 A 38 year old woman presents with swollen neck. Her blood pressure is 190/115 mmHg. Investigations: Serum Calcium 2.9 mmol/L (N 2.25 – 2.6 mmol/L) Creatinine 130 µmol/L (N 60 – 140 µmol/L ) Resting Calcitonin - normal T3 2.8 nmol/L (1.2 – 3 nom/L) TSH 3mU/l ( 1-6 mU/l) 1. What is the most likely diagnosis? 20

21. Answer 10 1. Multiple Endocrine Neoplasia – MEN IIa or Sipple’s Syndrome Raised calcium – parathyroid adenoma Mass in the neck with normal T3 and TSH – Medullary carcinoma of thyroid Hypertension - Phaeochromocytoma 21

22. X RAYS & ECGs

23. Question 11 1. What is the diagnosis? 23

24. Answer 11 1. Pleural Effusion 24

25. Question 12 1. What is the diagnosis? 25

26. Answer 12 1. Left sided Pneumothorax 26

27. Question 13 1. What is the diagnosis? 27

28. Answer 13 1. Tension Pneumothorax 28

29. Question 14 1. What is the diagnosis? 29

30. Answer 14 1. Mitral stenosis (Left border of the heart is straight, there is a loss of concavity in its shape) 30

31. Question 15 1. What is the diagnosis? 31

32. Answer 15 1. Left ventricular aneurysm (there is outward and upward bulge of left ventricular apex) 32

33. Question 16 1. What is the diagnosis? 33

34. Answer 16 1. Pericardial Effusion Heart shadow is enlarged and globular in shape and covers both hila 34

35. Question 17 35 Patient presented with Raynauds Phenomenon What do you see in this X Ray Hand?

36. Answer 17 36 Soft Tissue Calcification Osteolysis Systemic Sclerosis

37. Question 18 1. What will you do? 37 This is X-ray abdomen of a young child. He swallowed an engagement ring incidentally.

38. Answer 18 1. Should pass spontaneously 38

39. Question 19 1. What is heart rate ? 2. See the rhythm strip, what do you find ? 39

40. Answer 19 1. Heart rate 50/minute (Sinus Bradycardia) 2. APCs – Atrial Premature Contractions 40

41. Question 20 1. What is heart rate ? 2. What abnormality do you find? 41

42. Answer 20 1. Heart rate 94/minute 2. Left axis deviation VPC – Ventricular Premature Contraction 42

43. Question 21 1. What is the diagnosis ? 43

44. Answer 21 1. Ventricular Tachycardia – wide complex tachycardia 44

45. Thank you 45