100 Diagnostic Challenges in Clinical Medicine

David R Ramsdale

• Publisher: WSPC
• Year: 2009
• ISBN:
  9789814365284
• Topic: Medicine
• Subtopic: Internal Medicine & Diagnosis

100 Diagnostic Challenges in Clinical Medicine is composed of one hundred well-illustrated clinical scenarios and their appropriate investigations. A wide variety of specialties are covered including cardiology, neurology, dermatology, endocrinology, tropical medicine, haematology, metabolic medicine, radiology, ophthalmology, venereology, and infectious diseases. Presenting the relevant investigations corresponding to each case in an interesting and easy-to-read Q&A format concerning diagnosis and management, this book serves as an ideal, and hopefully enjoyable, study aid for medical students and junior doctors who are preparing for clinical examinations in medicine. By solving the problems posed by these challenging clinical cases, the reader will gain additional practice in diagnosis and treatment strategies.

Readership: Medical students; doctors preparing for higher examinations; practicing clinicians.

Case 1

Following a syncopal episode at home, this 39-year-old man suffered from a fractured clavicle. He admitted to being breathless on effort and complained of difficulty in walking and poor vision. His facial appearance and his electrocardiogram (ECG) are shown below.

Q

Questions:

1. What three features are shown in the picture?
2. What might explain his poor vision?
3. What is the clinical diagnosis? How is this condition inherited?
4. Which chromosome is abnormally affected?
5. What is the ECG diagnosis?
6. What precise treatment should he receive?

A

Answers:

1. Frontal balding, bilateral ptosis and long, haggard expressionless features.
2. Cataracts and external opthalmoplegia.
3. Dystrophia myotonica. Autosomal dominant.
4. Chromosome 19.
5. Complete heart block.
6. Dual chamber permanent pacemaker implantation.

Case 2

A 50-year-old lady complained of painful lower legs over the previous seven days. She had a four-year history of mild hypertension and a ten-year history of ulcerative colitis for which she received sulphasalazine.

Q

Questions:

1. Describe the lesions.
2. What is this condition? What is the pathology?
3. With what is it associated?
4. What is the usual outcome and what treatment could be given?

A

Answers:

1. Multiple raised red areas on the shins, which are tender.
2. Erythema nodosum. Panniculitis.
3. It may be associated with sarcoidosis, tuberculosis, rheumatic heart disease and streptococcal infection. It can also be seen in approximately 5% of patients with an exacerbation of inflammatory bowel disease. Females are affected three times more frequently than males. Drug hypersensitivity (e.g. oral contraceptives, penicillin) may be a cause as well.
4. Some severe lesions may ulcerate but are rarely chronic. They usually resolve with steroid therapy or after colectomy.

Case 3

This 75-year-old man presented with cough and a large amount of haemoptysis. He had previously been treated for pulmonary tuberculosis with triple therapy and chronically expectorated large volumes of pale-green coloured sputum. In the last six months, the sputum had become progressively more blood stained.

Q

Questions:

1. Name three abnormalities on this chest X-ray.
2. What investigation has been performed here?
3. What is the diagnosis?
4. What simple tests might help confirm the diagnosis?
5. What treatment should be recommended?

A

Answers:

1. (i) Proximal bronchiectasis in right mid-zone.
   (ii) Bilateral hilar shadowing.
   (iii) Large cavitated lesion in left upper zone.
2. Bronchography.
3. Aspergilloma. The mycetoma is seen inside a large cavity in the left upper zone.
4. Fungal culture of sputum or bronchopulmonary lavage; serum IgG precipitins to Aspergillus fumigatus.
5. Left upper lobectomy with resection of mycetoma.

Case 4

A 60-year-man presented with angina of effort and exertional syncope. Physical examination revealed a small volume, anacrotic carotid pulse and an ejection systolic murmur at the left sternal edge. The left lateral chest X-ray and the M-mode echocardiogram are shown below.

Q

Questions:

1. What does the lateral chest X-ray show?
2. What does the M-mode echocardiogram show?
3. What is the diagnosis?
4. What is the next investigation required?
5. What treatment is indicated?

 

A

Answers:

1. A ring of calcification on the aortic valve.
2. Heavy (black) calcification on the aortic valve. (Ao = aorta; LA = left atrium)
3. Calcific aortic stenosis.
4. Cardiac catheterisation and coronary arteriography for assessment of the aortic valve gradient and the coronary anatomy.
5. Aortic valve replacement.

Case 5

A 72-year-old man with a history of previous coronary artery bypass surgery and percutaneous coronary intervention to the saphenous vein grafts to the obtuse marginal branch of the circumflex artery and left anterior descending artery, complained of fatigue and dyspnoea of effort. He weighed 115 kg at 5 ft 10 in. Blood pressure was 140/80 mmHg, heart sounds were normal. Haemoglobin 11.6 g/dL; white cell count 20 000/µL; platelets 130 000/µL; ESR 40 mm in the first hour. The peripheral blood film is shown below.

Q

Questions:

1. What is the likely diagnosis?
2. Name the cell type.
3. What other clinical features should be looked for?
4. What two other investigations are indicated?
5. What treatment should be given?

A

Answers:

1. Chronic lymphatic leukaemia.
2. B cell.
3. Lymphadenopathy, splenomegaly.
4. Bone marrow aspiration, lymphocyte cell typing.
5. No specific treatment for the leukaemia at present, but n...