Cardiology C A S E 1 Rheumatic Heart Disease BRIEF HISTORY An 18-year-old girl was admitted through out-patient department with six hours history of severe left sided chest pain. For the last four months, she had increasing shortness of breath and fatigue on exertion with swelling of her ankles. During the last four hours of her chest pain, her breathlessness had worsened. There was no history of haemoptysis. She had mild unproductive cough for the last three months. The chest pain was described as sharp with no radiation and was worse on deep breathing. She had been given frusemide 40 mg daily for her swollen legs and had also been started on digoxin 0.25 mg once a day a week before her admission. Her doctor had given her pethidine 50 mg parenterally before sending her to the hospital, but this had failed to control her pain. She had no known drug allergies. She could remember having frequent sore throats as a child, but there was no clear history of joint pains. One of her brothers, however, had a heart condition and had been treated with medicines for a long time. IMPORTANT CLUES ON CLINICAL EXAMINATION On examination, she was very dyspnoeic and had central cyanosis. She was apyrexial. JVP was raised by 4 cm. There was moderate pitting oedema over her both legs. Her throat was normal. Blood pressure was 120/70 mm Hg. There was no clubbing or lymphadenopathy. Clinically she was euthyroid. Her pulse was 110 per minute and irregularly irregular. Peripheral pulses were palpable. Apex beat was tapping in character and she had a left parasternal heave. The first heart sound was loud and she had a rough, rumbling, mid-diastolic murmur localized to the apex.

Infectious Diseases C A S E 2 Left Atrial Myxoma BRIEF HISTORY A 35-year-old man presented to the cardiology outpatient with a history of fever, malaise and palpitations for the last four months. The fever was low grade and intermittent in character. On one occasion, he developed sudden pain in the left leg which became pale, cold and heavy. Two weeks prior to his recent visit to the hospital, he had a syncopal attack and recovered spontaneously. There was no history of chest pain but occasionally he had dyspnoea on exertion. IMPORTANT CLUES ON CLINICAL EXAMINATION On examination, he looked pale and a bit anxious. Temperature was 99.4 ° F. General physical examination was normal. Pulse was 96 per min, regular and good volume with all peripheral pulses palpable. BP was 130/85 mm Hg. First heart sound was split with accentuation of the pulmonic component of second heart sound and mid-diastolic murmur at mitral area. Chest examination revealed bilateral basal crackles. Abdominal and neurological systems were normal. INVESTIGATIONS Investigations included: Hb: 9.8 g/dl Blood sugar: 4.4 mmol/l (79 mg/dl) (normocytic Blood urea: 8 mmol/l (48 mg/dl) normochromic) Creatinine: 108 umol/l (1.2 mg/dl) WCC: 8.8 × 10 9 / l Urine: normal P:76% L:20% ECG: sinus rhythm, no M:2%E:2% ischaemic changes Contd...

Infectious Diseases C A S E 3 Infective Endocarditis BRIEF HISTORY A 60-year-old woman was admitted through the outpatient clinic with a four-month history of weight loss, loss of appetite and fever with rigors and night sweats. She also complained of increased breathlessness and tiny reddish lesions on the palms and pulp of the fingers which were painful. She also had some dragging sensation in the left hypochondrium. In the past, she was operated for mitral valve stenosis by valvotomy. She was a known hypertensive and diabetic. IMPORTANT CLUES ON CLINICAL EXAMINATION On examination, she looked pale and had a temperature of 100 ° F. She was clubbed and there were a few streaks in her nails. Pulse was 108 per minute regular, and all the pulses were palpable. Heart sounds were normal, but there was a pan-systolic murmur at mitral area which radiated towards left axilla. Chest was clear but abdominal examination revealed splenomegaly. Neurological examination was normal. INVESTIGATIONS Investigations included: H b : 8.4 g/dl Urine: traces of albumin (normocytic and a few normochromic) RBCs per high power field seen. WBC: 16.6 × 10 9 / l Chest X-ray: mitralization of the P:71% L:21% left border of heart M:5% E:3% with prominent Contd...

Infectious Diseases C A S E 4 WPW Syndrome BRIEF HISTORY A 27-year-old man presented to the accident and emergency department with a history of palpitations. He said that he had such palpitations quite often and on two occasions felt dizzy as well. There was no history of fever, chest pain, dyspnoea on exertion, undue intolerance to heat or weight loss. There was no past history of painful swollen joints during adolescent period. He was not a known hypertensive or diabetic. He smoked ten cigarettes a day. IMPORTANT CLUES ON CLINICAL EXAMINATION On examination, he looked well and in good health. Pulse was 90 per minute, good volume, regular, and all pulses were palpable. His JVP was not raised and heart sounds were normal. Blood pressure was 125/80 mmHg. His chest was clear. Abdominal and neurological examinations were normal. INVESTIGATIONS Investigations were as follows: Hb: 15 g/dl Chloride: 98 mmol/l (normocytic Urine: normal normochromic) WBC: 7.9 × 10 9 / l Chest X-ray: normal P:75% L:20% ECG: as shown in M:3%E:2% Figure 4.1 ESR: 04 mm in 1st hour Echocardiogram: normal Platelets: 290 × 10 9 /l Sodium: 138 mmol/l Potassium: 4.

Infectious Diseases C A S E Acute Pericarditis 5 BRIEF HISTORY A young man presented with chest pain which was retrosternal in origin. The pain was sharp, pricking in character and aggravated while lying down, but he got a little relief while sitting up. He gave history of an upper respiratory tract infection accompanied by fever about five days ago. He was a non-smoker. There was no history of trauma, hypertension or diabetes. IMPORTANT CLUES ON CLINICAL EXAMINATION On examination, he looked anxious. Temperature was 102 ° F. Pulse was 110 per minute, regular, good volume and all pulses were palpable. Cardiovascular system revealed normal heart sounds, but there was some scratchy noise over the precordium. Both lungs were clear on auscultation. Abdominal and neurological examinations were normal. INVESTIGATIONS Investigations included: H b 15 g/dl Potassium: 4.8 mmol/l (normocytic Bicarbonate: 24 mmol/l normochromic) Chloride: 98 mmol/l WBC: 7.5 × 10 9 / l Chest X-ray: lungs clear and heart P:60% L:35% size normal M:3%E:2% Platelets: 250 × 10 9 / l ECG: as shown in Figure 5.

Infectious Diseases C A S E Inferior Myocardial Infarction 6 BRIEF HISTORY A man of 47 was admitted with a three-hour history of central chest pain and shortness of breath. His pain radiated to the left shoulder and lower jaw and was moderate-to-severe in intensity. He was diagnosed to have exertional angina three months ago and was advised to lose weight and take angised tablets as required. He had been tried 3 such tablets before coming to the hospital but with no relief. He had been attending a wedding party and ate heavy meals night before and thought the pain might have been due to indigestion, therefore, he had also tried some antacids, but this did not help the pain either. He had felt nauseated in the last two hours and had profuse, cold sweating on the forehead. He had been fit and healthy until three months ago. He lived with his wife, had two sons, 18-and-16-years old. He had been smoking 25 cigarettes a day for over 25 years until three months ago when he stopped smoking on his doctors advice. His father died at the age of 53, his mother was 68 and healthy and one brother, 51 was also in good health. IMPORTANT CLUES ON CLINICAL EXAMINATION On examination, he was obese, JVP was not raised. Blood pressure was 130/70 mmHg. Pulse was 68 per minute with occasional extrasystoles. Respiration was 20 per minute. There was no cyanosis, thyroid enlargement or lymphadenopathy. Heart sounds were normal. He had a soft, systolic, apical murmur with no radiation. Trachea was central. Breath sounds were normal with a few left basal crepitations. Examination of abdomen and central nervous system was normal.

Infectious Diseases C A S E Left Ventricular Aneurysm 7 BRIEF HISTORY A 54-year-old man was admitted with a history of gradually increasing breathlessness for the last three months. A month prior to his recent visit, he developed sudden weakness of his left half of face and body which lasted for about 12 hours and gradually recovered. He also complained of swelling of both feet and had palpitations. There was history of dry cough but no sputum, haemoptysis or fever. On a few occasions, he had paroxysmal nocturnal dyspnoea. In the past four years, he has had two attacks of myocardial infarction and on the second occasion his stay was about two weeks in the hospital. He used to smoke 20 cigarettes a day but stopped smoking an year ago. IMPORTANT CLUES ON CLINICAL EXAMINATION On examination, he was breathless even at rest. Pulse was 110/ min, regular. Blood pressure was 115/75 mmHg. His JVP was raised by 3 cm. Apex beat was diffuse and double in character. Heart sounds were feeble with an S3 gallop. Chest revealed bibasal crackles. There was pedal oedema. Liver was enlarged 3 cm below right subcostal margin and was tender and smooth in consistency. Neurological examination was unremarkable. INVESTIGATIONS Investigations revealed: Hb: 14.5 g/dl Chloride: 98 mmol/l (normocytic Blood urea: 5.0 mmol/l (30 mg/l) normochromic) Creatinine: 114 umol/l (1.3 mg/dl) l Contd...

Pulmonology C A S E Pulmonary Embolism 8 BRIEF HISTORY A 45-year-old woman was admitted in gynaecology ward for hystrectomy because of recurrent vaginal bleeding due to fibroids. On the second postoperative day she spiked temperature of 100 ° F which lasted for one day only. She had a very low threshold for pain and was reluctant to mobilize. Otherwise she was progressing well. On the seventh postoperative day, she suddenly became breathless and started complaining of pain in the left side of chest. The pain was pleuritic in nature. There was no history of haemoptysis but dry cough was present. IMPORTANT CLUES ON CLINICAL EXAMINATION On examination, she was orthopnoeic, looked exhausted and there was central cyanosis as well. Pulse was 140 per minute regular and BP was 100/70 mmHg. Heart sounds revealed wide splitting of second heart sound. Chest expansion was diminished on the left side and there was decreased air entry. Abdominal and neurological examinations were normal. There was no evidence of deep venous thrombosis in the legs. INVESTIGATIONS Following investigations were performed: Hb: 13.4 g/dl Potassium: 3.4 mmol/l (normocytic Bicarbonate: 26 mmol/l normochromic) Chloride: 100 mmol/l WCC: 9.2 × 10 9 / l Blood urea: 5.0 mmol/l (30 mg/dl) P:78% L:18% Blood sugar: 8 mmol/l(144 mg/dl) M:2%E:2% Contd...

Pulmonoloy C A S E Empyema 9 BRIEF HISTORY A 43-year-old man was admitted to medical ward via accident emergency department with a four-day-history of fever with rigors and sweats at night. He also complained of discomfort in the right side of chest and it used to get worse on coughing and sneezing. He had decreased appetite and also had lost about 4 kg in weight during this course of illness. Two weeks prior to the present illness, he had high grade fever and pleuritic pain on the same side and was admitted to a hospital where, according to the patient, some fluid was taken out from his right side of the chest, but then he improved with antibiotics. He had no family history of chest or heart disease and there was no history of hypertension or diabetes. He smoked 15 to 20 cigarettes a day. No allergies were noticed. IMPORTANT CLUES ON CLINICAL EXAMINATION On examination, he looked toxic and obviously in discomfort. Temperature was 103 ° F and there was no pallor, cyanosis, jaundice, clubbing or lymphadenopathy. BP was 145/92 mmHg and pulse was 118 per minute. Chest examination revealed decreased expansion on the right side of the chest, stony dull on percussion with decreased air entry on auscultation in the right lower chest. Cardiovascular, abdominal and neurological examinations were normal.

Pulmonary C A S E Pulmonary Tuberculosis 10 BRIEF HISTORY A 52-year-old man attended the outpatient department with a history of low-grade fever, cough, purulent sputum for the last three months. He told that his chest had never been right as he had recurrent chest infections and for the last three months, he had noticed some blood in his sputum. Six months ago, he was diagnosed to suffer from diabetes mellitus for which he was taking some medications. He complained of easy fatigueability and weight loss with night sweats. He had been a heavy smoker. No allergies were noticed. IMPORTANT CLUES ON CLINICAL EXAMINATION On examination, he was rather anxious. Temperature was normal. There was mild cyanosis of the tongue but no lymphadenopathy, clubbing or jaundice was seen. Pulse was 88 per minute, regular and BP was 140/85 mmHg. Chest revealed fine rhonchi bilaterally, but coarse crackles over the right upper and mid zone. Abdominal, cardiovascular and neurological examinations were normal. INVESTIGATIONS Investigations included: Hb: 12.2 g/dl Blood urea: 11.3 mmol/l(68 mg/dl) (normocytic Creatinine: 90 umol/l (1.0 mg/dl) normochromic) Blood sugar: 14 mol/l (252 mg/dl) WCC: 9.9 × 10 9 / l Urine: traces of proteins, P:64% L:33% sugar++ M:2%E:1% ECG: normal Contd...

Pulmonary C A S E Atypical Pneumonia 11 BRIEF HISTORY A 26-year-old man was admitted with a six-days-history of flu-like symptoms, malaise, headaches, chest pain and unproductive cough. He complained of fever with rigors and felt extremely weak. He did mention a little trouble in his left ear. For the last three-days he was taking ampicillin without any benefit. In the past he had always been fit and healthy. There were no other significant systemic symptoms. He was a smoker and smoked twenty cigarettes per day. No allergies were noticed. IMPORTANT CLUES ON CLINICAL EXAMINATION On examination, he looked toxic, disorientated and dehydrated. Blood pressure was 150/85 mmHg. Pulse was 96 per minute and regular. Temperature was revealed 101.4 ° F. Thyroid and lymph nodes were not enlarged. No clubbing or oedema was noticed. Trachea was central and breath sound revealed widespread crepitation without pleural rub or bronchial breathing. Left auroscopy showed bulging tympanic membrane. Abdominal, cardiovascular and neurological examinations were normal. INVESTIGATIONS Following were the investigations: Hb: 13.9 g/dl Bicarbonate: 23 mmol/l (normocytic Chloride: 98 mmol/l normochromic) Blood urea: 10.8 mmol/l (65 mg/dl) Contd...

Pulmonary C A S E Pleural Effusion 12 BRIEF HISTORY A 62-year-old woman attended outpatient department with two- month history of progressive shortness of breath on exertion, undue tiredness, poor appetite and loss of weight. There was no history of cough, expectoration or haemoptysis. There were no urinary or bowel symptoms and she was not taking any drugs. She did mention that she felt a little sweaty and feverish at night. Her husband had some respiratory problems for which he was treated with medicines for many months. IMPORTANT CLUES ON CLINICAL EXAMINATION On examination, she was dyspnoeic. JVP was not raised. There was no anaemia, clubbing, cyanosis, oedema or lymphadenopathy. Trachea was central. Over her right base posteriorly, she had dullness on percussion with absent breath sounds. Apex beat was in left fourth intercostal space well inside midclavicular line. She had no heart murmurs. Examinations of abdomen and central nervous system were normal. INVESTIGATIONS Following were the results of various investigations: Hb: 11.6g/dl Bicarbonate: 24 mmol/l (normocytic Chloride: 98 mmol/l normochromic) Blood sugar: 13.3 mmol/l (23.9 mg/dl) WCC: 8 × 10 9 / l Blood urea: 7.5 mmol/l (45 mmg/dl) P:72% L:25% Creatinine: 87 umol/l (0.9 mg/dl) M:2% E:1% Urine analysis: protein ++ Contd...

Pulmonary C A S E Lobar Pneumonia 13 BRIEF HISTORY A 34-year-old man was brought to accident and emergency department with four-day history of high grade fever and rigors. The illness started with generalized aches and pains and then he developed cough which was dry to begin with but later on became productive. He also complained of severe chest pain on the right side, especially on deep breathing and coughing. He had enjoyed good health, but smoked 10 to 15 cigarettes a day. He was treated by local doctors with injections and tablets but there was little relief of his symptoms. He coughed rusty coloured sputum in the casualty department. IMPORTANT CLUES ON CLINICAL EXAMINATION On examination, he was confused with toxic look and had a temperature of 104 o F. His pulse was 130 per minute and BP was 120/70 mm Hg. He looked pale but was not cyanosed or jaundiced and there was no lymphadenopathy either. His breathing was very rapid and there were few crusty, papular lesions over his upper lip too. Chest examination revealed dullness to percussion on the right side with bronchial breathing. Cardiovascular, abdominal and neurological systems were normal. Investigations were carried out as follows: Hb: 12.5 g/dl Bicarbonate: 22 mmol/l (normocytic Chloride: 96 mmol/l normochromic) Blood urea: 6 mmol/l (36 mg/dl) WBC: 29×10 9 / l Creatinine: 70 umol/l (0.8 mg/dl) P:86% L:8% M:2% Blood sugar: 7.2 mmol/l (129 mg/dl) Contd...

Pulmonary C A S E Bronchiectasis 14 BRIEF HISTORY A 28-year-old man attended the outpatient clinic with a long history of cough and copious amount of purulent sputum. He could recall this since his childhood. The cough and sputum had decreased in severity on quite a few occasions. A week prior to his visit, he had coughed some bright red blood mixed with sputum. He also complained of increased breathlessness after a bout of cough or exertion. There was no history of fever, but he did complain of malaise, lethargy and weakness. In the past, he had whooping cough, but there was no history of diarrhoea or vomiting. He was a non-smoker. IMPORTANT CLUES ON CLINICAL EXAMINATION On examination, he looked emaciated. Temperature was 98.4 ° F. He had clubbing of his fingers. Pulse was 86 per minute and regular. BP was 125/80 mmHg. Chest examination revealed coarse crackles on both bases. No pleural rub was audible. Cardiovascular, abdominal and neurological examinations were normal. INVESTIGATIONS Investigations included: Hb: 10.8 g/dl Bicarbonate: 23 mmol/l (normocytic Sputum: numerous pus cells and normochromic) bacteria WBC: 11.4 × 10 9 / l Chest X-ray: prominent broncho P:78% L:20% vesicular marking in M:2% both lower Contd...

Pulmonary C A S E Lung Abscess 15 BRIEF HISTORY A 55-year-old man presented to accident and emergency department with a history of haemoptysis. The blood he coughed was fresh, bright red with a few clots in it. He gave history of pneumonia about two months ago which, according to him, got complicated and he was given a number of antibiotics while in the hospital. He complained of undue tiredness, malaise and fever with rigors and sweating. He did mention that since his discharge from the hospital, he had been coughing up greenish sputum which sometimes was copious in amount but never coughed blood like this before. He smoked 15 to 20 cigarettes a day. He was not known hypertensive or diabetic and there was no history of tuberculosis either. IMPORTANT CLUES ON CLINICAL EXAMINATION On examination, he looked toxic and anxious. Temperature was 100 ° F. General physical examination revealed pallor and clubbing of fingers. Pulse was 100 per minute and regular. JVP was not raised and heart sounds were normal. Chest showed central trachea with bronchial breathing in the right midzone. Course crackles were also present there. Abdominal and neurological examinations were unremarkable. INVESTIGATIONS Investigations included: Hb : 11.4 g/dl Blood sugar 6 mmol/l (115 mg/dl) (normocytic Urine: normal normochromic) Sputum: Contd...

Pulmonary C A S E Bronchogenic Carcinoma 16 BRIEF HISTORY A 61-year-old man was admitted with history of progressive cough, mucoid sputum and haemoptysis for the last three weeks. He had smoked 20 cigarettes a day for over forty years and had a smokers cough in the morning for over 13 years. Before this, he had been treated for chest infection with antibiotics, but it did not get better. He had good appetite and had not lost weight recently. There was no history of chest pain, palpitations, urinary or bowel problems. IMPORTANT CLUES ON CLINICAL EXAMINATION On examination, he looked well. JVP was not raised. There was no anaemia or cyanosis. Lymph nodes and thyroid were not enlarged. He had early clubbing of his fingers, more marked on the left side. Trachea was central. He had an area of bronchial breathing with a few crepitations at his right base. Examinations of cardiovascular, abdomen and nervous system were unremarkable. A day after his admission, he had a grand mal epileptic fit. INVESTIGATIONS Investigations were as follows: Hb: 11.4 g/dl Bicarbonate: 25 mmol/l (normocytic Chloride: 101 mmol/l normochromic) Blood urea: 5.0 mmol/l (30 mg/dl) WCC: 9.7 × 10 9 / l Creatinine: 128 umol/l (1.4 mg/dl) P:78% L:19% Blood Sugar: 6 mmol/l(108 mg/dl) M:2% E:1% Contd...

Pulmonary C A S E Cor Pulmonale 17 BRIEF HISTORY A 54-year-old man was admitted with fourteen-month history of progressive shortness of breath on exertion. There was no history of wheezing or diurnal variation. For last one month, he had started having an unproductive cough, and two weeks ago, he had arthralgia involving his ankle and knee joints which settled with paracetamol tablet within three days. There was no history of chest pain, loss of weight or appetite. He had no pets at home. He had ulcerative colitis for the last twelve years, but for the last three years, his colitis was quiet and he was not taking any drugs. IMPORTANT CLUES ON CLINICAL EXAMINATION On examination, he was dyspnoeic and centrally cyanosed. There was marked clubbing of his fingers but had no enlargement of lymph nodes or thyroid. Blood pressure was 160/90 mmHg, and pulse was 88 per minute and regular. There was pitting oedema of both his ankles and the JVP was raised by 8 cm. Skin was normal with no subcutaneous nodules or ulceration. Trachea was central, but the chest expansion was limited, and he had bilateral fine inspiratory crepitations over his lung bases. He was in sinus rhythm but had left parasternal heave and a loud pulmonary component of second heart sound. His liver was 3 cm enlarged, soft and tender with no associated splenomegaly or ascites. Examination of the nervous system was normal.

Gastroenterology C A S E Cholangitis 18 BRIEF HISTORY A 62-year-old woman was admitted with two-day-history of severe right-sided abdominal pain and vomiting. She also felt febrile and had shakes with it. There was no history of cough, expectoration or chest pain. The pain was constant in the right hypochondrium without any radiation. She had not been able to eat or drink much because of this illness. IMPORTANT CLUES ON CLINICAL EXAMINATION On examination, her temperature was 101 ° F. Blood pressure was 90/50 mmHg. Pulse was 120 per minute and regular. JVP was not raised. There was no anaemia, clubbing, thyroid or lymph node enlargement. She was quite dehydrated and mildly icteric. On abdominal examination, there was marked guarding and tenderness in her right hypochondrium, but there was not definite hepatomegaly. Spleen was not palpable and there was not ascites either. Bowel sounds were audible. Respiratory, cardiovascular and neurological examinations were normal. INVESTIGATIONS Following were the results of various investigations: Hb: 14.8 g/dl Creatinine: 138 umol/l (1.5 mg/dl) (normocytic Bilirubin: 28 umol/l (1.6 mg/dl) normochromic) Total proteins: 5.8 g/dl WCC: 24 × 10 9 / l Albumin: 2.8 g/dl P:88% L:8% Blood Culture: E coli growth sensitive M:2% E:2% to cephalosporin. Contd...

Gastroenterology C A S E Oesophageal Varices 19 BRIEF HISTORY A 65-year-old man was brought to the accident and emergency department with a history of vomiting of copious amount of blood. The relatives did mention that he also vomited blood one day prior to this and passed dark-coloured stools. He also felt dizzy at that time. He was not a known hypertensive or diabetic but smoked ten cigarettes a day. Three years ago, he had an attack of jaundice which lasted for two weeks. The wife told that he complained of generalised weakness and bloating of his abdomen for the last three weeks. IMPORTANT CLUES ON CLINICAL EXAMINATION On examination, he was drowsy and sweating profusely. Restlessness was also evident. He looked cachectic and pale. Pulse was 120 per minute and regular but low volume. BP was recorded as 80 mmHg systolic only. Heart sounds were normal. Chest was clear. Abdomen showed tense ascites. Liver was not palpable. Neurological examination showed bilateral upgoing plantars. INVESTIGATIONS Investigations included: Hb: 5.5 g/dl Blood sugar: 4 mol/l(72 mg/dl) (normocytic Blood urea: 14 mmol/l (84 mg/dl) normochromic) Creatinine: 110 umol/l (1.2 mg/dl) WCC: 10.6 × 10 9 / l Urine: protein++, blood++ P:72% L:22% ECG: sinus tachycardia, M:4% E:2% no evidence of ischaemia Contd...

Gastroenterology C A S E Amoebic Liver Abscess 20 BRIEF HISTORY A 45-year-old man presented to the accident and emergency department with one-week history of high grade fever and rigors accompanied by profuse sweating. He had noticed undue weakness and loss of appetite. Most of the time he felt nauseated and vomited on couple of times. Four weeks prior to present condition, he developed loose motions with occasional blood and mucus in the stools, but it settled after some medications from the doctor. He complained of pain in the abdomen which was more marked on the right side. He had been well in the past apart from occasional attacks of bronchitis. He smoked 20 to 25 cigarettes per day. There was no family history of any disease. IMPORTANT CLUES ON CLINICAL EXAMINATION On examination, he looked toxic. Temperature was 104 ° F. Pulse was 130 per minute and regular. BP was 120/80 mmHg. Abdominal examination revealed mild tenderness in the right hypochondrium and liver was just palpable. Spleen was not enlarged and bowel sounds were present. Rectal examination was normal. Cardio- vascular, respiratory and neurological examinations were normal. INVESTIGATIONS Following investigations were ordered: Hb: 13.4 g/dl Blood urea: 8 mmol/l (48 mg/dl) (normocytic Blood sugar: 6 mmol/l (108 mg/dl) normochromic) Creatinine: 1.2 umol/l (1.2 mg/dl) WCC: 15.4 × 10 9 / l Urine: normal Contd...

Gastroenterology C A S E Malabsorption 21 BRIEF HISTORY A 62-year-old woman was admitted with-eight-week history of diarrhoea, weight loss, tiredness and lethargy. She denied having any abdominal pain or vomiting, but admitted that she had lost about 7 kg of weight. Diarrhoea was in the form of 3 to 5 loose motions a day without blood or mucus. The colour of faeces was pale, and she had noticed at times that she had to flush the toilet repeatedly, since the stools either floated or tended to stick to the closet. At times, they were foul smelling too. She had always been fit. There was no past history of such an illness, diabetes or hypertension. IMPORTANT CLUES ON CLINICAL EXAMINATION On examination, she looked pale. JVP was not raised, but she had pitting oedema on both feet. There was no clubbing, lymphadeno- pathy or jaundice. Blood pressure was 145/85 mmHg, and pulse was 80 per minute and regular. The thyroid gland was enlarged, but clinically she was euthyroid. In the abdomen there were no scars. Liver and spleen were not enlarged. Examinations of respiratory, cardiovascular and nervous system were normal. INVESTIGATIONS Following investigations were available: Hb: 8.5 g/dl Blood sugar: 7.4 mmol/l (133 mg/dl) (macrocytic Total protein: 5.7 g/dl normochromic) Albumin: 3.2 g/dl WCC: 9 × 10 9 / l Alk.phos: 280 u/l Contd...

Gastroenterology C A S E Hepatic Encephalopathy 22 BRIEF HISTORY A 45-year-old male was brought to accident and emergency department after a severe bout of haemoptysis and sudden deterioration in the level of consciousness. The brother mentioned that a year ago he had jaundice which lasted for about a month and then he took some medicines from Hakims and got a bit better but continued to have malaise, increased tiredness and easy fatigueability. The patient had also noticed that his abdomen was bloating and legs were swelling up, too. One week prior to this, he vomitted blackish fluid. His wife had noticed that for the last few days, he was becoming increasingly sleepy and behaved in a strange way. He was also becoming forgetful and irritable. There was no history of recent drug intake, but he was taking laxative more often without much success. He was not a known diabetic or hyper- tensive. IMPORTANT CLUES ON CLINICAL EXAMINATION On examination, he looked pale and was very drowsy and responded only to painful stimuli. He had mild jaundice. There was no clubbing, cyanosis or lymphadenopathy. Poedal oedema was noticed. His pulse was 130 per minute and regular. BP was 105/65 mm Hg. Cardiovascular and respiratory systems were normal. Abdominal examination showed tenderness in the epigastrium, liver was not palpable, spleen was just palpable and there was moderate ascites. There were no signs of meningeal irritation, but the reflexes were exaggerated with upgoing plantars.

Gastroenterology C A S E Constipation 23 BRIEF HISTORY A 58-year-old woman was admitted with a history of frequency of micturition for two days. She had also suffered from severe osteoarthritis mainly affecting her knees and left hip for which she was taking, paracetamol regularly for the last two years. For the last three weeks, she was started on some stronger pain killers since paracetamol was not enough to control her pain. Because of her increasing pain, she had been getting depressed for the last six months and had become almost housebound. She used to cry and complained of insomnia and took sleeping pills. She was not a known hypertensive or diabetic. IMPORTANT CLUES ON CLINICAL EXAMINATION On examination, she looked depressed and was mildly confused. JVP was not raised. Blood pressure was 140/70 mmHg. Pulse was regular. Thyroid and lymph nodes were not enlarged. There was no clubbing, oedema or jaundice. She had painful limitation of movements of both her knees and left hip. Her abdomen was distended and soft masses could be palpated all along the left side of it. Bowel sounds were rather more active. On rectal examination, she was impacted and a finger was stained with soft faeces and mucus but no blood. Examinations of the cardiovascular and respiratory systems were normal. There were no localising neurological signs except she had small sized pupils.

Gastroenterology C A S E Intestinal Obstruction 24 BRIEF HISTORY A 68-year-old woman presented to the accident and emergency department with a two-day history of generalized abdominal pain which was followed by vomiting for twenty hours before admission. She had no fever, cough, expectoration, chest pain or palpitation. There were no urinary symptoms, but she had no bowel action for the last five days and was passing no wind or faeces per rectum. She was not a diabetic or hypertensive, but had a history of osteo- arthritis and parkinsonism for which she was on a few medicines. IMPORTANT CLUES ON CLINICAL EXAMINATION On examination, she was dehydrated and kyphoscoliosis was obvious. Blood pressure was 140/60 mmHg. Pulse was 88 per minute and regular. There was no clubbing, anaemia, thyroid swelling or lymph node enlargement. She was mildly confused and could not remember her own address. Abdomen was distended with some irregular mass in the left iliac fossa along the descending colon. Bowel sounds were faintly audible. Rectal examination confirmed the presence a large amount of faeces. No masses were palpable and the finger was not blood stained. She had rest tremors and some rigidity in her limb, but could walk without any difficulty. INVESTIGATIONS Following were the results of various investigations: Hb: 14 g/dl Blood urea: 12 mmol/l (72.6 mg/dl) (normocytic Creatinine: 140 umol/l (1.6 mg/dl) normochromic) Blood sugar: 9 mmol/l (162 mg/dl) Contd...

Gastroenterology C A S E Mesenteric Infarction 25 BRIEF HISTORY A man of 73 was admitted with a two-hour history of sudden severe central abdominal pain, vomiting and diarrhoea. There was no history of haematemesis or malaena. He was known to suffer from ischaemic heart disease, atrial fibrillation and diabetes mellitus. His diabetes had been well controlled on oral hypoglycaemic agents. Other drugs included isordil and digoxin. On the day of this pain, he had taken his usual food and tablets. There was no history of headaches, fits or faints. IMPORTANT CLUES ON CLINICAL EXAMINATION On examination, he was in pain and sweaty over forehead. Blood pressure was 110/70 mmHg. Pulse 84 per minute and irregular. Thyroid and lymph nodes were not enlarged. No anaemia, clubbing or cyanosis was noticed. His pulse was mightily irregular with an apical rate of 100 per minute and had soft systolic apical murmur. Respiratory system was normal. In the abdomen, he had diffuse periumbilical tenderness but no guarding or rebound tenderness was noticed. Bowel sounds were faintly audible. Rectal examination was normal. Examination of nervous system was unremarkable. INVESTIGATIONS Following were the results of various investigations: Hb: 13.4 g/dl Creatinine: 270 umol/l (3.0 mg/dl) (normocytic Protein: 7.2 g/dl normochromic) Albumin: 3.6 g/dl Contd...

Gastroenterology C A S E Ulcerative Colitis 26 BRIEF HISTORY A 27-year-old man presented to the accident and emergency department with a history of passage of loose motions for the last two days. The stools he was passing were mixed with blood and mucus and were about 10 to 12 per day. He also mentioned about fever and abdominal discomfort. There was no history of drug intake and on further questioning he told that he had been passing loose motions off and on for the last two months and they were sometimes containing mucus and blood for which he took medicine from his doctor but never had such an attack before. One of his uncles also had similar problems but ultimately died of heart attack. IMPORTANT CLUES ON CLINICAL EXAMINATION On examination, he looked toxic, dehydrated, anaemic and wasted. Temperature was 102 ° F. Pulse was 120 per minute regular and all pulses were palpable. BP was 110/70 mmHg. Heart sounds were of normal intensity with an ejection systolic murmur at aortic area. There was minimal poedal pitting oedema. Chest was clear. Abdomen was distended and tympanitic. It was tender in left iliac fossa. No viscera were palpable. Rectal examination by the finger showed blood and mucus. INVESTIGATIONS Investigations included: Hb: 7.8 g/dl Potassium: 3.8 mmol/l (microcytic Bicarbonate: 24 mmol/l hypochromic with Chloride: 98 mmol/l few tear drop cells) Urine: normal Contd...

Gastroenterology C A S E Acute Pancreatitis 27 BRIEF HISTORY A 39-year-old woman was brought to the accident and emergency department with a history of severe epigastric pain, vomiting and fever for one day. There was no history of malaena or haemetemesis. She had complained of mild epigastric discomfort especially after fatty meals and used antacids and carminatives which relieved her symptoms temporarily. She was not a known diabetic or hyper- tensive. One of her cousins had died of a heart attack recently, otherwise there was nothing else significant in the family history. No allergies were noticed. IMPORTANT CLUES ON CLINICAL EXAMINATION On examination, she was restless and had sweating on her forehead. Temperature was 99.4 ° F. Pulse was 120 per minute and regular, and BP was recorded at 90/60 mmHg. She looked to have mild jaundice. Cardiovascular system was normal, while respiratory system showed decreased breath sounds on right side at the base. Abdominal examination showed tender epigastrium but no masses or viscera were palpable. Neurological examination was unremarkable. INVESTIGATIONS Investigations included: Hb: 13.2 g/dl Urea: 6.8 mmol/l (41 mg/dl) (normocytic Creatinine: 117 umol (1.3 mg/dl) normochromic) Bilirubin: 34 umol/l (2.0 mg/dl) Contd...

Gastroenterology C A S E Carcinoma Colon 28 BRIEF HISTORY A 65-year-old gentleman attended the outpatient clinic with a history of increased breathlessness, swelling of feet, easy fatigueability and weight loss for about two months. His appetite was moderate and there was no history of any drug intake. He also complained of pain in the chest on exertion which subsided after taking rest. For the last three months, he had noticed some change in his bowel movement. He had occasional diarrhoea and sometimes constipation. He also noticed that for the last four weeks, his piles were troubling him more in the way of bleeding. He stopped smoking about five years back. One of his uncles died of cancer of stomach. IMPORTANT CLUES ON CLINICAL EXAMINATION On examination, he looked a bit anxious. Pallor was obvious, but there was no jaundice. Minimal pitting oedema of both feet was noticed. Pulse was 100 per minute and BP was 149/90 mmHg. Auscultation of precordium revealed an ejection systolic murmur. Respiratory system was unremarkable. On abdominal examination, descending colon was palpable and was loaded, probably, with faeces. Liver or spleen was not palpable and there was no ascites. Two haemorrhoids of second degree were present. INVESTIGATIONS Investigations revealed: Hb: 6.9 g/dl Bicarbonate: 29 mmol/l Microcytic Urine: normal hypochromic Liver function with pencil and tests: normal tear drop cells. Chest X-ray: normal lung marking Contd...

Gastroenterology C A S E Peptic Ulcer 29 BRIEF HISTORY A 60-year-old lady was taken to the doctor by her son with three- month history of general ill health, tiredness, swelling of legs and occasional confusion. The doctor found that she was pale and in mild heart failure and arranged for haemoglobin and other blood tests. Her haemoglobin was found to be 5.6 g/dl and she was admitted to the hospital for further investigations and treatment. She denied having abdominal pain but did admit to occasional indigestion and belching. There was no history of loss of appetite or weight, urinary or bowel symptoms. She was not a known diabetic or hypertensive and was taking no medications. IMPORTANT CLUES ON CLINICAL EXAMINATION On examination, she was anaemic and mildly confused. Blood pressure was 130/70 mmHg, pulse 88 per minute and regular and she had pitting oedema over both ankles. JVP was raised by two cm. There was no clubbing, cyanosis, thyroid enlargement or lymphadenopathy. Her liver was 3 cm. enlarged, soft, smooth and tender. There was no epigastric mass or tenderness and no splenomegaly or ascites. She had a few bilateral basal crackles. She was in sinus rhythm and had a soft systolic murmur at the apex without radiation. There were no localising neurological signs. INVESTIGATIONS Following were the results of various investigations: Hb: (repeated) 5.6 g/dl Blood sugar: 6 mmol/l (108 mg/dl) MCV: 72fl Blood urea: 11 mmol/l (66 mg/dl) Contd...

Gastroenterology C A S E Primary Biliary Cirrhosis 30 BRIEF HISTORY A 56-year-old lady was referred to the medical outpatient clinic with an eight-month history of pruritus. She had loose motions for the last four weeks and felt generally tired. There was no history of loss of weight or appetite. She had been applying calamine lotion over her skin but with little relief though diarrhoea was a little better with kaopectate given by her doctor two days ago. She also had history of passing dark urine and pale stools and someone told her that her eyes had turned yellow as well. She was also worried about darkening of her skin. IMPORTANT CLUES ON CLINICAL EXAMINATION On examination, she was mildly icteric and had clubbing of her fingers. There was no lymphadenopathy or glandular enlargement. Blood pressure was 170/100 mmHg. Pulse rate was 80 per minute and regular. Her skin was a little dry and pigmented and she had scratch marks all over her body with bilateral xanthelasmae. Respiratory and cardiovascular systems were normal. Abdominal examination showed that liver was 6 cm enlarged, firm, smooth, and non-tender. The spleen was 3 cm enlarged and she had some shifting dullness but no definite fluid thrill could be elicited. Neurological examination was normal. INVESTIGATIONS Her initial investigations were as following: Hb: 11g/dl Blood sugar: 4.9 mmol/l (88 mg/dl) (normocytic Blood urea: 3.5 mmol/l (21 mg/dl) normochromic) Creatinine: 110 umol/l (1.2 mg/dl) Contd...