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CASE HISTORYDr. Zahoor

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A 50 year old woman is transferred with a 7 day history of increasing confusion and vomiting. She is markedly dehydrated. Urgent investigations show:

- Blood glucose of 50mmol/L, - Urine dipstick 1+ ketone, - Arterial blood gas (ABG) - bicarbonate

20mmol/L and - pH 7.35. - Serum Na - 150mmol/L, K - 5mmol/L - Urea 20mmol/L

CASE 1 – Topic: DM

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1. What is the likely diagnosis? a. Diabetic ketoacidosis (DKA) b. Hyperosmolar non-ketotic confusion (HONK) c. Lactic acidosis d. DKA in a patient with previously undiagnosed type I diabetes

2. Serum osmolality should be calculated according to which equation?

a. 2(Creatinine + Urea) + Glucose + Na b. 2(glucose + Na) + urea c. 2(Na + K) + glucose + urea d. 2(urea + glucose)

What is the serum osmolality in this patient?

Case 1 - Questions

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3. Which of the following statement is true? a. She will need life long insulin in view of her high

blood glucose level b. DKA is uncommon in type I diabetes c. Undiagnosed diabetes mellitus is the commonest

cause of DKA d. Most cases of HONK (Hyperosmolar non-ketotic

confusion) are associated with undiagnosed type 2 diabetes

Case 1 - Questions

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Answer to Question 1. b. Hyperosmolar non-ketotic confusion (HONK)

Answer to Question 2. c. 2(Na + K) + glucose + urea Serum osmolality is 380 milli-osmoles/kg

Answer to Question 3. d. Most cases of HONK (Hyperosmolar non-

ketotic confusion) are associated with undiagnosed type 2 diabetes

Case 1 - Answers

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A 50 year old woman is referred to out patient because she feels tired all the time. On further questioning, she has noticed constipation and thinning of her hair. On examination, she appears pale, over weight and has a smoothly enlarged thyroid gland. Full blood count shows Hb – 10.5g/dL and mean cell volume (MCV) – 100 fL.

CASE 2 – Topic: Thyroid Gland

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1. On further examination she is most likely to demonstrate which of the following?

a. Sinus tachycardia b. Sinus bradycardia c. Pigmentation of the skin creases d. Exopthalmos

2. What are biochemistry tests likely to show? a. Decreased T4 and Increased TSH b. Increased T4 and decreased TSH c. Decreased T4 and decreased TSH d. Increased T4 and increased TSH

Case 2 - Questions

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3. Which of the following drug treatment may also cause hypothyroidism?

a. Digoxin b. Aspirin c. Insulin d. Amiodarone

4. What is the diagnostic significance of positive peroxidase antibodies?

a. Addisons disease b. Pernicious anaemia c. Autoimmune thyroid disease d. Thyroid cancer

Case 2 - Questions

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Answer to Question 1. b. Sinus bradycardia

Answer to Question 2. a. Decreased T4 and Increased TSH

Answer to Question 3. d. Amiodarone Note – Amiodarone treatment may cause either hypo or hyper

thyroidism due to its high iodine content and structural similarity to thyroxine

Answer to Question 4. c. Autoimmune thyroid disease

Case 2 - Answers

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A 35 year old woman is transferred to casualty with an irregular heart beat. On examination, she is sweaty and warm, but finds it difficult to sit still. She is noted to have staring eyes and can not write her name and address legibly. On examination, patient is in Atrial fibrillation at a rate of 110 beats/min. She has difficulty raising her arms above her head. The thyroid gland is slightly enlarged and has an audible bruit.

CASE 3 – Topic: Thyroid Gland

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1. Biochemistry is most likely to show which of the following?

a. Positive islet cell antibodies b. Increased T4 and increased TSH c. Increased T4 and decreased TSH d. Decreased T4 and Increased TSH

2. Following a likely diagnosis of Graves’ disease, a thyroid

uptake scan is performed. What does this show? a. A diffusely ‘cold’ gland due to reduced uptake b. A diffusely ‘hot’ gland due to increased uptake c. A single ‘cold’ nodule d. Multiple ‘hot’ spots

Case 3 - Questions

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3. What is the appropriate first line treatment of the underlying condition?

a. Emergency thyroidectomy b. Radio-iodine c. Antithyroid drugs d. Thyroxine

Case 3 - Questions

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Answer to Question 1. c. Increased T4 and decreased TSH

Answer to Question 2. b. A diffusely ‘hot’ gland due to increased

uptake

Answer to Question 3. c. Antithyroid drugs (Carbimazole or

Propylthiouracil)

Case 3 - Answers

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A 58 year old man comes to see you because of shortness of breath. He has experienced mild dyspnea on exertion for a few years, but more recently he has noted worsening shortness of breath with minimal exercise and the onset of dyspnea at rest. He has difficulty reclining and as a result, he spends the night sitting up in a chair trying to sleep. He reports a cough with production of yellowish brown sputum every morning throughout the year.

Long CASE HISTORY

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He denies chest pain, fever, chills, or lower extremity edema. He has smoked about two packs of cigarettes per day since age 15 years. He does not drink alcohol. A few month ago, the patient went to clinic for evaluation of his symptoms, and received a prescription for some inhalers, the names of which he does not remember. He was also told to find a primary care physician for further evaluation.

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On physical examination, his blood pressure is 135/85mmHg, heart rate 96bpm, respiratory rate 28 breaths per minute and temperature 97.6oF. He is sitting in a chair, leaning forward, with his arms braced on his knees. He appears uncomfortable with laboured respirations and cyanotic lips. He is using accessory muscles of respiration and chest examination reveals wheezes and rhonchi bilaterally, but no crackles are noted.

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The anteroposterior diameter of the chest wall appears increased, and he has inward movement of the lower rib cage with inspiration. Cardiovascular examination reveals distant heart sounds but with a regular rate and rhythm, and his jugular venous pressure is normal. His extremities show no edema or clubbing.

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1. What is the most likely diagnosis?

2. What is the next best diagnostic test?

3. What is the best initial treatment?

Questions:

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1. Chronic Obstructive pulmonary disease (COPD) with acute exacerbation

2. Arterial blood gas to assess oxygenation and acid base status

3. Oxygen by nasal cannula, followed closely by bronchodilators and steroids for inflammatory component

Answers:

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Thank you