Case History

A 56 years old man came to mountain resort clinic on a mountain peak, with c/o
dyspnoea, headache, dizziness & inability to sleep, the person arrived at resort
one day before from the sea level town and has no current health issues or
medication.

QUESTIONS
1)What is Probable diagnosis?

Ans : -Acute mountain sickness.

2) What do you advise?

Ans:- Advise to return to sea level and Supplement oxygen.

3) How do you treat if patient wants to stay in resort for 1 week

Ans:- Oxygen therapy

Carbonic acid (CA) inhibitor- Acetazolamide to correct respiratory acidosis

as acetazolamide is a diuretic

Increased water intake is advised.

Case History
A 36 years’ male is brought to emergency department with C/o headache,
vertigo, dizziness and confusion.

On taking H/O of it is winter season and patient used kerosene stove as heater.
His neighbour noticed kerosene smell and smoke from patient’s house.

QUESTIONS
1) What is the probable diagnosis?

Ans: - Carbon Monoxide Poisoning

2) What is the cause of the hypoxia in this patient?

Ans:- Carbon monoxide displaces O2 from O2 binding sites of Hb.

3) How do you treat the patient?

Ans:- By giving hyperbaric Oxygen.

Case History
A diver who went in to the sea up to 40 feet depth ascended suddenly to the sea
level. He started complaining of muscle pains, joint pains, tingling sensations
and difficulty in breathing.

QUESTIONS

1) What is your likely diagnosis?

Ans:- Decompression sickness ( Caisson’s disease)

2)What are the complications?

Ans:- Diver’s palsy- Motor paralysis

Chokes- Blockage of capillaries in lungs

Bends-severe pain in joints and muscles of limbs.

3)How do you prevent the condition?

Ans:- Slow ascent

Use of oxygen- helium mixture in Scuba

4) How do you manage the condition?

Ans:- Use of Decompression chamber- Slow recompression

CASE HISTORY
A 50 years old man complains of cough and shortness of breath on exposure to
dust and cold. He complains of hearing of musical sounds from the chest during
expiration. On auscultation of lungs wheeze is heard.

QUESTIONS
1) What is your likely diagnosis?

Ans:- Chronic obstructive pulmonary disease (COPD)- Bronchial asthma.

2) What is the cause of wheeze?

Ans:- Bronchial narrowing during expiration due to bronchoconstriction,

hypersecretion of mucus and mucosal edema.

3)What happens to vital capacity?

Ans:- Vital capacity remains normal, FEV1 Decreases.

 CASE HISTORY
Mr Prasad brings his son aged 12 years studying 7 th standard with a complaint of
headache and not able to see clearly what is written on the black board in class
room.

QUESTIONS
1) What is the probable visual defect?

Ans:- Myopia / Short sightedness.

2) What type of lens is used for correction?

Ans:- Biconcave lens

3) What other advise you give?

Ans:- More vitamin A intake

Good light while studying

Restrict use of cell phones or computer.

CASE HISTORY
Mr Kumar comes with severe headache and vomitings, he was referred to
ophthalmologist.

 Visual acuity is normal

 In perimetry for visual fields - bitemporal hemianopia.

QUESTIONS
1) Where is the site of lesion in visual pathway?

Ans:- Central part of optic chiasma.

2) What is the probable cause?

Ans:- Supracellar aneurysm / Tumour of pituitary gland

CASE HISTORY
You are in the medical board of railway recruitment selection.

The subject comes for eye check-up.

QUESTIONS
1) What tests do you advise?

Ans:-visual acuity, colour vision.

2) What are the test for colour vision?

Ans:- Ishihara charts.

Edridge green lantern.

Wool sorting test

3)what charts are used for visual acuity?

Ans:- Snellen’s chart for distant vision

Jaegers chart for near vision.

CASE HISTORY
A 45 years old person comes with C/O difficulty in hearing. On taking H/O the
patient works in an industry where he is exposed to excessive noise for
prolonged time.

On tuning fork tests.

Rennies AC>BC

Weber’s test sound lateralized to healthy ear.

Absolute bone conduction is reduced.

QUESTIONS
1) What is the type of hearing loss?

Ans:- Sensorineural deafness.

2)What is the cause of deafness?

Ans:-Damage of hair cells by excessive noise.

 CASE HISTORY
A woman aged 30 years got up in the morning suddenly got down from the bed,
she immediately felt light headedness and thought that she would fall. Heart
rate increased, later she became normal.

QUESTIONS
1) What is your diagnosis?

Ans:- Postural hypotension.

2) What is the reason for light headedness?

Ans:- Because of hypotension there is reduced blood supply to brain

(Transiently)

3) What is the reason for tachycardia?

Ans:- Activation of baroreceptor reflex.

4)How she became normal?

Ans:- Because of activation of baroreceptor reflex BP comes to normal.

CASE HISTORY
An individual brought to the hospital who met with an accident. He showed the
following signs and symptoms.

Restlessness, extreme weakness, pale, cold clammy skin, rapid thready

pulse, hypotension and oliguria.

BP 90/60 mm of Hg PR 120/min.

QUESTIONS
1) What is your diagnosis?

Ans:- Hypovolemic shock.

2)What are the causes for circulatory shock?

Ans:- Haemorrhage, vomitings, diarrhoea and burns.

3)What is the cause for cold clammy skin / Tachycardia / hypotension?

Ans:-

Cold clammy skin- Decreased cutaneous circulation due to shifting of blood

from skin to the vital organs.

Tachycardia- Hypotension triggers circulatory reflexes.

Hypotension- Due to loss of blood volume

4) What immediate treatment you suggest?

Ans:- IV Fluids, whole blood in case of haemorrhage.

CASE HISTORY
A 52 years old male who is morbidly obese has occasional chest pain releived by
nitroglycerine. One evening he felt sick, and went to bed early, he woke up at
2AM with constricting pain in the chest and pain is radiating down to left arm
and was not relieved by nitroglycerine, got nausea and sweating profusely and
also had difficulty in breathing. Shifted to hospital.

On examination:

BP 100/80mm of Hg

Ejection fraction 35%

LDH and Creatinine Phosphokinase increased

ECG – T wave inversion in chest leads

QUESTIONS
1) What is your diagnosis?

Ans:- MI (Myocardial infraction)

2)What are the findings in favour of diagnosis?

Ans:- Decreased BP and Ejection fraction.

Increased cardiac enzymes.

T wave inversion.

3)what is the cause for decreased ejection fraction?

Ans:- Decreased stroke volume due to reduced left ventricular efficiency.

CASE HISTORY
A 68 years old male a known case of Myocardial infarction(MI) on treatment,
had fainting spells twice and brought to the hospital.

His ECG showed P waves are not followed by QRS complex and after few
minutes ECG returns to normal.

QUESTIONS

1) What is your diagnosis?

Ans:- A-V Block.

2) What is P-R Interval, what is the normal value?

Ans:- Interval from beginning of P wave to beginning of QRS complex.

Normal 0.12 to 0.21 sec

3) What is the cause for A-V nodal delay?

Ans:- Fibres connecting the internodal tracts and A-V node are very small
and conduct impulses at a very slow rate.

RMP of these fibres is more negative than rest of the cardiac muscle fibres
as a result, A-V nodal action potential is slower to develop.

4)What is the cause for fainting spells?

Ans:- After AV block it takes time to develop idioventricular rhythm results in

fainting spells.

5)Different types of A-V Block?

Ans:- 1st Degree, 2nd Degree and 3rd degree blocks.

CASE HISTORY
A 38 years old woman gets fatigued easily with regular routine work. Within 6
months She developed dyspnoea at rest, swelling in her legs, feet.

On examination

Jugular veins distended, liver enlarged and ascites (Collection of fluid in the
abdomen) present. X ray showed right ventricular hypertrophy and prominent
pulmonary vasculature.

ECG Rt ventricular hypertrophy changes.

QUESTIONS
1) What is your diagnosis?

Ans:-Pulmonary hypertension with right ventricular failure.

2) Why did increased pulmonary vascular resistance cause increase in

pulmonary arterial pressure (Pulmonary hypertension)?

Ans:- Blood has to be pumped against increased resistance hence pulmonary

arterial pressure increased.

3) What is the after load of right ventricle and left ventricle?

Ans:- Right ventricle – Pulmonary arterial pressure

Left ventricle- Peripheral resistance.

4) What is the cause for right ventricular hypertrophy?

Ans:- Right ventricle has to pump the blood against increased resistance
leads to hypertrophy.

5) What is the cause for oedema?

Ans:- Venous stasis due to decreased venous return.

CASE HISTORY
A patient comes to a doctor with constricting pain behind the sternum, pain
radiating to the ulnar border of left arm. Severity of the pain is proportional to
the degree of exertion. Pain also increased after meals and in cold weather.

X ray chest Normal

ECG – Normal

QUESTIONS
1) What is your diagnosis?

Ans:- Angina pectoris.

2) Why was ECG Normal what does it signify?

Ans:- No infarction in myocardium due to transient ischemic attack.

3) What advise should be given to such patients?

Ans:- Reduce stress and strain and life style modification.

Regular cardiac evaluation.

CASE HISTORY
A 40 years old male was suffering with inflammatory bowel disease since 20
Years. Gradually he failed to respond to medical management. Recently he had
small bowel obstruction and underwent emergency surgery and 80% of his ileum
was resected. Since surgery he had diarrhoea with pale oily fowl smelling stools.

He receives monthly injections of Vitamin B12

QUESTIONS

1) What is your likely diagnosis?

Ans: - Bile acid deficiency.

2)What is the cause for fowl smelling oily stools?

Ans: - Due to the presence of unabsorbed fat.

3)What is the importance of Vitamin B12 injection?

Ans: - Due to the resection of ileum, vitamin B12 is not absorbed.

CASE HISTORY
A 35 years old business executive complains of pain in the upper abdomen,
which is relieved on taking food, his basal secretion of Hcl was 6 meq /d and
secretion during augmented histamine test is 35 meq / d

QUESTIONS
1) What is your diagnosis?

Ans: - Peptic ulcer.

2) Why is pain relieved on taking food?

Ans: - presence of food neutralizes the acid.

3) Normal value of augmented histamine test?

Ans: - 10-25meq.

4) Mention other agent which is used to stimulate Hcl production?

Ans: - Pentagastrin.

5) What is the effect of vagotomy in this patient?

Ans: - Decreased stimulation for Hcl production.

CASE HISTORY
A 30 years old female came to hospital with vomitings since 3 days she could
not retain even oral fluids.

On examination.

She could not hold her head up

BP 90/60 mm of Hg.

Dry mucous membranes and decreased skin turgor.

Lab reports.

Arterial blood: PH 7.6 (N 7.4), Hco3 3.7 (N 2.4), Pco2 45 mmHg (N 40 mm Hg)

Venous blood: Na+ 137 meq/l (N 140 meq/l),

Cl- 82 meq/l (N 105 meq/l),

K+ 2.8 meq/l (N 4.5meq/l)

On infusion of isotonic saline and K+ she recovered.

QUESTIONS
1) What is your likely diagnosis?

Ans: - Hypokalaemic, hypochloremic metabolic alkalosis due to vomitings.

2) What is the basis for this acid base disorder?

Ans: - loss of K+ and Cl- in Vomitings.

3)what is the cause for reduced BP?

Ans: - Loss of circulating blood volume.

3) Why she could not lift her head?

Ans: - Due to Hypokalaemia.

CASE HISTORY
A 30 years old male has developed severe diarrhoea and inspite of medication
he had 8-10 watery stools per day.

He became progressively weak and taken to the hospital.

On examination.

Eyes are sunken, mucous membranes dry, JVP collapsed.

Pale, cold and clammy skin,

BP 60/40mm/Hg , PR 120/mt,

RR 24/mt Breathing was deep and rapid

Lab reports.

Arterial Blood:

PH 7.2 (N 7.4),

PCo2 24mm of Hg (N 40 mm Hg)

Venous blood:

Na+ 132 meq/l(N140meq/l),

K+ 2.3 meq/l (N 4.5 meq/l),

Cl 111 Meq/l (N 105 meq/l)

On treatment with strong Antidiarrheal medicines and infusion of Nacl and KHCo3 he
was normal.

QUESTIONS
1) What is your likely diagnosis?

Ans :- Metabolic acidosis due to diarrhoea

2) What is the cause of this acid base disorder?

Ans:- Loss of electrolytes Na+, k+ and Hco3

3) What is the cause for deep rapid breathing?

Ans:- Increased H+ ions  increased H2Co3 formation.

Which dissociates in lungs to H2o and Co2. Co2 stimulates respiratory

centres. Deep rapid breathing.

4) What is the cause for hypotension?

Ans:- Loss of body fluids ------ Blood volume decreased.

CASE HISTORY
A 35 years old woman underwent Thyroidectomy 2 years back. During surgery
there was accidental damage to the parathyroid glands. Recently she went to
see her doctor as she developed tingling sensations, numbness, stiffness and
cramps of extremities. When the doctor was recording the BP he observed that
her hand went into spasm.

QUESTIONS
1) What is your likely diagnosis?

Ans: - Hypocalcaemia due to hypoparathyroidism (Tetany)

2) What is the sign called as?

Ans: - Trousseau’s sign (Obstetrician’s hand)

3) What is the other sign you can elicit in this condition?

Ans: - Chvostek’s sign

4) What investigations you suggest?

Ans: - Estimation of serum calcium levels.

CASE HISTORY
A couple married 6 years ago do not have children. They consulted a
gynaecologist and underwent all routine investigations for infertility.
Investigations of the wife are normal. Husband’s sperm count is found to be
20milllions/cu mm.

QUESTIONS
1) What is normal sperm count?

Ans: - 60 to 120 million / cu mm

2)what is azoospermia?

Ans: - Absence of spermatozoa in the semen.

3)What are the hormones regulating spermatogenesis?

Ans: - Testosterone, FSH and LH

CASE HISTORY
A female aged 30 years, on exposure to severe cold in winter had deviation of
mouth to the right side. There is loss of expressions, loss of nasolabial fold and
dribbling of saliva on the left side. She could not close her left eye even during
sleep completely.

QUESTIONS
1) What is your likely diagnosis?

Ans: - Facial nerve palsy ( Bell’s palsy).

2) Which side of facial nerve affected?

Ans: - Left sided facial nerve affected.

3) What are the types of nerve palsies?

Ans:- Infranuclear palsy

Supranuclear palsy

CASE HISTORY
A 10 years old school going child was observed by his teacher that he is dull,
slow in learning and short in stature when compared to his classmates. His
mother is found to be hypothyroid.

QUESTIONS
1) What is your likely diagnosis?

Ans: - Cretinism

2) What is the cause of the condition?

Ans: - Hypothyroidism of the mother.

3) What are the investigations to be done?

Ans: - Thyroid function tests (Estimation of TSH, T3 and T4)

4) How could you have been prevented this condition?

Ans: - By giving thyroxine to the mother during pregnancy.

CASE HISTORY
A 54 years old male complains of headache and muscle weakness since few
days. Headache was not relieved by analgesics.

On examination:

His BP was 180/100 mm of Hg

Lab reports:

Na+ - 145 meq /l

K+ - 2 meq/l

QUESTIONS
1) What is your likely diagnosis?

Ans: - CONN’s syndrome (Hyperaldosteronism)

2) What is the cause of hypertension?

Ans: - Due to retention of Sodium and Water.

3) What is the cause of hypernatremia and hypokalaemia?

Ans: - Aldosterone stimulates the reabsorption of Sodium causing retention of

Sodium in exchange potassium is lost.

CASE HISTORY
A middle aged individual comes with a history of weakness, increased thirst,
increased excretion of urine and increased appetite. He also complains of loss of
weight and poor healing of the wound.

Investigations reveal:

Urine examination shows sugar but no ketone bodies

Fasting blood sugar level …. 160mg/dl

QUESTIONS
1) What is your diagnosis?

Ans: - Diabetes mellitus

2) How do you explain polyuria, polydipsia and polyphagia?

Ans: - Excessive excretion of water in the urine along with glucose

Polyuria causes increased intake of water and stimulation of Thirst

centre in the hypothalamus causing polydipsia.

Excessive excretion of glucose in the urine causes polyphagia.

3) Absence of ketone bodies in the urine suggest what?

Ans:- Absences of ketone bodies in the urine suggests that diabetes is well
managed without complications.
CASE HISTORY
A female aged about 28 years came with history of tiredness, restlessness,
nervousness and excessive sweating, palpitation and amenorrhoea.

On examination:

There was tachycardia, fine tremors of outstretched hands, the skin was warm
and front of the neck was prominent. There is protrusion of eyeballs and eyelids
were retracted.

Investigation:

BMR …. 40%

Serum Cholesterol … 100 mg%

Basal pulse rate .. 120/min

QUESTIONS
1)What is your diagnosis?

Ans:- Hyperthyroidism

2) Comment on the investigation report?

Ans: - Increased oxygen consumption and catabolism causes increased heat

production and increased BMR.

T4 decreases cholesterol

Increased sympathetic activity - Increases heart rate

3) What is the cause for the protrusion of eyeballs?

Ans:- Increase in extra orbital tissues, from the fat and extra ocular muscles.

4) What other investigations would you suggest to confirm the diagnosis?

Ans: - Thyroid function tests (Estimation of TSH, T3, and T4)

CASE HISTORY
A patient was admitted in the hospital with multiple fractures after a trivial
injury. Investigations revealed low serum calcium levels.

QUESTIONS
1) Which endocrine dysfunction could have led to this condition?

Ans: - Hypoparathyroidism.

2) What changes would you expect in the X ray appearance of his bones?

Ans : - Diffuse skeletal hyperostosis (Osteosclerosis).

CASE HISTORY
A young girl aged 10 Years is very short statured for her age. What are the 2
possible endocrine causes. Mention 3 signs and symptoms that will differentiate
the two conditions.

Ans : -Dwarfism and cretinism.

Dwarfism Cretinism
1.Normal mental activity 1.IQ is low (Mental retardation)

2.Growth is proportionate 2.Growth is disproportionate

3.Noraml sexual activity 3. Sexual dysfunction
CASE HISTORY
A male patient aged about 35 years is presenting with enlargement of peripheral
parts of the body (Hands and feet) with prognathism and overgrowth of frontal
and other facial bones, more body hair, gynecomastia and visual defects.

QUESTIONS

1) What is the diagnosis?

Ans: - Acromegaly
2) What is the cause of enlargement of peripheral parts of the body and
what visual defects you expect?

Ans:- Action of excessive GH on the bones after the closure of epiphyseal

plates.

Bitemporal hemianopia.

3) What investigation do you suggest for the confirmation of the

diagnosis?

Ans: - Estimation of GH.

CASE HISTORY
A female about 55 years presents with cold intolerance, dry thick skin, poor
memory, constipation, weight gain, change in the voice and menorrhagia. On
examination patient is having bradycardia, periorbital oedema and non-pitting
oedema in the lower extremities.

QUESTIONS
1)what is your diagnosis?

Ans:- Hypothyroidism - Myxoedema

2)What investigation you suggest for the confirmation of diagnosis?

Ans: - Thyroid function tests – Estimation of TSH, T3 and T4

3)How do you treat the condition?

Ans: - By giving Thyroxine.

CASE HISTORY
A patient comes with a history of excessive drinking of water and passing of
excess of colourless urine very frequently. Investigations revealed that patient
passed about 15 lit of urine in 24 hrs. The urine was colourless and the specific
gravity was 1002 – 1004. There was no sugar, albumin or blood in the urine.

QUESTIONS
1) What is your diagnosis?

Ans:-Diabetes insipidus.

2) What is the cause for the development of Polyuria and polydipsia?

Ans:- Increased ADH secretion causes increased excretion of water in the

urine.

Increased excretion of water causes increased intake water and

stimulation of thirst centre.

3) In what other conditions polyuria occurs?

Ans:- Diabetes mellitus.

4) How to manage the condition?

Ans:-Hormonal therapy – ADH

Non – Hormonal Therapy - Chlorpropamide, thiazides (Diuretics),

Clofibrate , and carbamazepine.

CASE HISTORY
A female patient aged about 30 years reported that she was feeling very weak
and getting fatigued easily. Her arms and legs were thin with central obesity and
accumulation of more fat in the back. She is having moon face and reddish
purple striae observed on the abdomen her blood pressure was 160/100 mm Hg.
She had noticed that minor injuries were taking a long time to heal.

QUESTIONS
1) Identify the endocrine abnormality in this patient?

Ans:- Cushing’s syndrome

2) What is the cause of poor wound healing in this patient?

Ans:- Increased fat causes decreased blood flow to the tissues,

Immunosuppression and decreased fibroblastic activity.

3) What change may be expected in the blood sugar value of this patient?

Ans:- Increased blood glucose levels (Hyperglycaemia)

4) What investigations do you suggest to confirm the diagnosis?

Ans:- Estimation of plasma cortisol and 24 hrs urinary free cortisol.

CASE HISTORY
A 5 years old boy complained of pain in the back and neck and had fever of
102 degrees F. On the following morning there was complete paralysis of the
right thigh, leg and foot. Muscular tone was greatly reduced and both superficial
and deep tendon reflexes were abolished. At the end of the month, the muscles
of the affected limb showed reaction of degeneration and marked atrophy and
there was no sensory loss.

QUESTIONS
1) What is your diagnosis?

Ans:- Poliomyelitis.

2) What type of lesion is it?

Ans:- Lower motor neuron (LMN) lesion

3) What is the cause?

Ans:- It is a viral infection in which the virus gets localized in the anterior

horn cells of the spinal cord and destroy them.

CASE HISTORY
A woman aged 63 years, suddenly fainted and became unconscious. When
consciousness regained, she was unable to move the left arm and leg. On
examination, it was found that there was spastic paralysis of left arm and leg
and at the end of 6 weeks, there was increased muscle tone and tendon reflexes
were exaggerated.

QUESTIONS
1) What is your diagnosis?

Ans:- Hemiplegia.

2) Where is the Probable site of the lesion?

Ans:- Due to the lesion of the corticospinal tract (Pyramidal tract) and the most

probable site of lesion is in the internal capsule. (But lesion can be at any

point from its origin down to the 5thc segment.)

3) What could be the cause?

Ans :- Most common cause is vascular – cerebral haemorrhage in middle

cerebral artery, infective origin or due to tumours in the brain.

CASE HISTORY
A 65 years old man presents with abnormal movements of thumb and index
fingers, his face is unexpressive or masked facies, difficulty to initiate any
movement with shuffling gait but there is no intellectual deficit and no sensory
loss.

QUESTIONS
1) What is your diagnosis?

Ans :- Parkinson’s Disease

2) Which part of the nervous system is involved in this disease?

Ans:- Nigrostriatal dopaminergic pathway of Basal ganglia.

3) What is the cause for this condition?

Ans:-

 Due to the degeneration of Nigrostriatal dopaminergic pathway.

 May be due to chronic use of drugs like phenothiazine and D2 receptor
blockers.
 Destruction of basal ganglia due to the excessive accumulation of MPP
(Methyl- Phenyl-Pyridinium)

4) What is the treatment?

Ans:-

 Levodopa(L-dopa)- a precursor of dopamine, can easily cross the BBB.

 Dopamine receptor agonists
 MAO inhibitor – Deprenyl –Drug of choice
 Anticholinergics
CASE HISTORY
A male aged about 65 years has come to the hospital was found to be having
scanning speech, defective coordinated body movements with unsteady gait.
There is no sensory deficit but rapid oscillatory eye movements were observed.

QUESTIONS
1) What is your diagnosis?

Ans:- Cerebellar dysfunction.

2) What clinical tests you employ to confirm the diagnosis?

Ans:- Cerebellar function tests :

 Tests for coordination:

In upper limbs: Finger nose test

Making circles in the air

In lower limbs: Knee heel test, making circles in the air.

 Test for cerebellar ataxia: Ask the patient to stand erect with feet
closed and eyes open.
 Assessment of gait : Made to walk on a straight line.
CASE HISTORY
A factory worker suffered an accidental injury on the back of the body which
resulted in the spastic paralysis of the right lower limb and loss of fine touch and
proprioceptive sensations like vibration sense and joint sense on the same side
(ipsilateral) with loss of pain and temperature sensation on the opposite
side(left).

QUESTIONS
1) What is your diagnosis?

Ans:- Brown sequard syndrome ( Hemisection of spinal cord)

2) What is the cause?

Ans:- It is due to the hemisection of spinal cord which may be due to injury

to the spinal cord or tumours affecting only half of the cord.

3) Give the reasons for differences in the sensory modulation?

Ans:- The fine touch and proprioceptive sensations are carried by dorsal or
posterior spinothalamic tract which ascends (First order neurons ) on the
same side of spinal cord till it reaches the medulla. In contrast, pain and
temperature are carried by lateral spinothalamic tract which crosses the
midline in the same spinal segment and ascends on the opposite side. Hence
fine touch and proprioceptive sensations are lost on the same side with loss
of pain and temperature on the opposite side as there is hemi section of
spinal cord.

4) What is the cause for spastic paralysis of right leg?

Ans:- It is due to the damage to the corticospinal tract on the side of

hemisection of spinal cord.

CASE HISTORY
A female aged 55 years come to a doctor with the complaint of intermittent
soreness of the tongue and periodic diarrhoea in addition to fatigue,
breathlessness, anorexia and pins and needle sensation. On examination the
skin and mucus membrane are pale, tongue is red and ulcerated, tachycardia is
present.

Investigations revealed

1. Histamine fast achlorhydria

2. RBC count – 1 million /cu.mm of blood.
3. RBC’s are irregular in size and shape.
4. Occasionally nucleated RBC’s present in peripheral blood.
5. Leukopenia.
6. Thrombocytopenia.

QUESTIONS
1) What is the type of anaemia in this patient?

Ans:- Megaloblastic anaemia.

2) What is the most probable cause of anaemia in this patient?

Ans:- Gastric atrophy leads to deficiency of intrinsic factor which inhibits

absorption of vitamin B12.

3) What are the principals involved in the treatment of this patient?

Ans:- Parenteral Vitamin B12 injections

CASE HISTORY
A woman aged 30 years complains of general fatigue, breathlessness on
exertion, giddiness, headache, palpitation, anorexia and dysphagia.

On examination the patient showed pallor of the skin and mucous membranes,
tachycardia, glossitis, spooning of the nails, (Sometimes tingling in the fingers
and toes) and oedema of the dependent parts of the body.

Investigations revealed

Haemoglobin :- 6 g/100ml

RBC Count: - 3 Million/ cu mm of blood.

MCHC :- 28 g/dl

MCV : 60 Cubic microns

WBC:- Eosinophilia

Stool examination: Hook worm ova present

QUESTIONS
1) What is the type of anaemia in this patient?

Ans:- Iron deficiency anaemia

2) What is the cause of anaemia in this patient?

Ans:- The hook worms adhere to the small intestinal mucosa and suck the blood

leading to anaemia.

3) Mention the principles involved in the treatment of this patient?

Ans:-

 Deworming
 Supplementation of iron
 If anaemia is severe transfusion of whole blood is given.
CASE HISTORY
A male child 3 years old was brought to a doctor with a complaint of bleeding
from the nose, mouth, urinary tract, alimentary tract and skin after trivial injury.
Sometimes swelling of joints with pain and fever was also noticed. The bleeding
was not profuse, but it was persistent. A careful history revealed similar bleeding
tendency in male relatives. Investigations revealed that the coagulation time
was prolonged. The bleeding time, prothrombin time and platelet count ware
normal.

QUESTIONS

1) What is the most likely diagnosis?

Ans:- Haemophilia

2)Why females are not usually affected by this bleeding disorder?

Ans:- Females are usually carriers of haemophilia. It is rare for a woman to

be affected because she needs to inherit faulty gene from both the

parents.

3)What are chances of the boy’s sister being a carrier?

Ans:- There is 50% chance of boy’s sister being a carrier.

4)What is the Physiological basis for treatment of this disorder?

Ans:-

 Giving clotting factor from human blood.

 Giving synthetic recombinant clotting factors.
 Desmopressin which stimulates the clotting factors.
CASE HISTORY
A young female exhibits abnormal fatiguability of muscles. Muscular
movements, though initially strong, rapidly gets tired as the day advances or
after a vigorous exercise. The symptoms to appear are ptosis, weakness for
chewing, swallowing and difficulty in speaking. She was unable to undertake
work above the level of the shoulder. The symptoms showed a remitting
course and often were precipitated by emotions and infections.

CNS – Normal. Remarkable recovery was seen after injection of neostigmine

intramuscularly.

QUESTIONS
1) What is your diagnosis?

Ans:- Myasthenia Gravis

2)What is the main cause for this condition?

Ans:- There is damage to the neuromuscular membrane at the neuro

muscular junction which leads to reduction in production of

Acetylcholine.This leads to defect in neuromuscular transmission.

3)How does injection of neostigmine improve the condition?

Ans:- Neostigmine is cholinesterase inhibitor which destroys Acetylcholine.

So it increases the amount of Acetylcholine and enhances neuro

muscular transmission.
CASE HISTORY
A 25- years old married woman has been menstruating regularly.

QUESTIONS
1) Mention a simple test to find out if she is ovulating or not?

Ans:-Recording of basal body temperature. There is rise in basal body

temperature by 1-degree Fahrenheit immediately after ovulation.

2) If she has missed her period recently, what simple test will you perform to
findout whether she is pregnant or not?

Ans:- Estimation of Human Chorionic Gonadotrophin in urine.

3) Mention the underlying basis of the test?

Ans:- The syncytiotrophoblastic cells of the placenta secrete Human Chorionic

gonadotrophin during pregnancy.

4) Mention one method she can use to plan her family?

Ans:- If the woman is nulliparous she is advised to take oral contraceptive

pills.

If the woman is having a child she is advised to go for intrauterine

contraceptive device.
CASE HISTORY
A patient comes to a doctor with a history of yellowish discolouration of the
sclera and skin. The stool was pale or clay coloured, bulky and foul smelling. He
also developed itching and loss of appetite.

On examination there was bradycardia. The sclera, mucous membranes and skin
were stained yellow.

Investigations revealed the following results

Stool Stercobilinogen --- Absent

Urine Bilirubin – Present
Blood Coagulation prolonged
Serum albumin Lowered
Serum bilirubin 6 mg/100ml
Liver function test Serum enzymes elevated
Vandenbergh test Direct positive

QUESTIONS
1) What is your diagnosis?

Ans:- Obstructive jaundice

2) Why the stool was pale, bulky and foul smelling?

Ans:- Pale stools are due to absence of stercobilin. Bulky and foul smelling

stools are due to presence of unabsorbed fat.

3) Why the Vandenbergh test was direct+ve?

Ans:- Vandenbergh test is direct positive due to presence of conjugated

bilirubin.