(BQ) Part 1 book “Case history and data interpretation in medical practice “ has contents: Case history and data interpretation, data interpretation of cardiac catheter, family tree, spirometry, pictures of multiple diseases.
Case History and Data Interpretation in Medical Practice Case History and Data Interpretation in Medical Practice Concerned mainly with Case Histories, Data Interpretation, Cardiac Catheter, Pedigree, Spirometry, Pictures of Multiple Diseases and a Brief Short Note Second Edition ABM Abdullah MRCP (UK), FRCP (Edin) Professor of Medicine Bangabandhu Sheikh Mujib Medical University Dhaka, Bangladesh JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD Kolkata • St Louis (USA) • Panama City (Panama) • London (UK) • New Delhi Ahmedabad • Bengaluru • Chennai • Hyderabad • Kochi • Lucknow • Mumbai • Nagpur Published by Jitendar P Vij Jaypee Brothers Medical Publishers (P) Ltd Corporate Office 4838/24 Ansari Road, Daryaganj, New Delhi - 110 002, India Phone: +91-11-43574357, Fax: +91-11-43574314 Registered Office B-3 EMCA House, 23/23B Ansari Road, Daryaganj, New Delhi - 110 002, India Phones: +91-11-23272143, +91-11-23272703, +91-11-23282021 +91-11-23245672, Rel: +91-11-32558559, Fax: +91-11-23276490, 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www.jphmedical.com • Europe Office, UK, Ph: +44 (0) 2031708910 e-mail: info@jpmedpub.com Case History and Data Interpretation in Medical Practice © 2010, Jaypee Brothers Medical Publishers (P) Ltd All rights reserved No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the author and the publisher This book has been published in good faith that the material provided by author is original Every effort is made to ensure accuracy of material, but the publisher, printer and author will not be held responsible for any inadvertent error(s) In case of any dispute, all legal matters are to be settled under Delhi jurisdiction only First Edition : 2006 Second Edition : 2010 ISBN 978-93-80704-45-6 Typeset at JPBMP typesetting unit Printed at ??? “Some patients, though conscious that their condition is perilous, recover their health simply through their contentment with the goodness of the physician.” — Hippocrates, 400 BC To National Professor N Islam Founder Vice Chancellor University of Science and Technology Chittagong, Bangladesh Preface to the Second Edition By the grace of Almighty Allah and the blessings of my well-wishers, I have been able to bring out the second edition of “Case History and Data Interpretation in Medical Practice” Enriched with new cases and pictures of a variety of clinical conditions, this edition will, I believe, exceed the popularity and success of the previous one Logical and accurate interpretation of clinical information is not only important to pass examinations but also necessary for management of patient It is an important and easy tool for quick and objective evaluation of knowledge and competence of a physician Hence, most modern examination systems have incorporated this technique The first edition of this book was published with the intention of helping students learn the basics of data interpretation and practice by themselves Its huge popularity and wide acceptance among students has encouraged me to upgrade the book and bring out this new edition All chapters of the previous edition have been fully revised to eradicate the mistakes and flaws One hundred more new clinical cases have been added I have tried to bring variety in clinical set-up and the amount of data provided in each set-up, so that students can learn to approach a problem from different points of view In addition, I have included data on cardiac catheterization and a whole new chapter on pictorial diagnosis, which contains 100 clinical pictures I have also tried to modify the book according to various helpful suggestions made by teachers and students I hope this new edition will be even more helpful for the students to learn and practice data interpretation I would like to invite constructive criticism and suggestions regarding this book from my readers, students, colleagues and doctors which would help me improve it further I would also like to acknowledge gratefully all the books and publications which I have consulted to gather information while writing this book I must apologize for any printing mistakes in this book Last but not least, I would like to express my gratitude to my wife and children for their untiring support, sacrifice and encouragement in preparing such a book of its kind Finally, I wish every success of my readers in all aspects of life ABM Abdullah Preface to the First Edition Case history and data interpretation are becoming a very important tool in clinical medicine These are designed and formulated in such a way that maximum time may be used by the candidate in thinking and minimum in writing, the best way of brain exercise I think, this will increase a doctor’s competence, confidence, efficiency and skill, in diagnosing a particular disease, formulating specific investigations and proper management Also, the best tool to be a good clinician and physician One must remember that specific answer is required, and if there are multiple possibilities, the best one should be mentioned Answer must be precise and specific, vague one should be avoided In this book, I have prepared many long and short questions with proper investigations, largely based on the real cases Answers are given with brief short notes of the specific problems, so that the candidate may get some idea without going through a big textbook Questions are fun to and answers are instructive I hope, postgraduate students and other equivalent doctors will find this book a very useful one and will enjoy the questions I not claim that this book is adequate for the whole clinical medicine and one must consult standard textbook I would invite and appreciate the constructive criticism and good suggestions from the valued readers I must apologize for the printing mistakes, which, in spite of my best effort, have shown their ugly face I gratefully acknowledge the publications and books, from where many information have been taken and included I am always grateful and thankful to all my students who were repeatedly demanding and encouraged me for writing such a book I am grateful to Kh Atikur Rahman (Shamim), Md Oliullah and Mr Biswanath Bhattacharjee (Kazal) for their great help in computer composing and graphic designing which made the book a beautiful and attractive one My special thanks to Mr Saiful Islam Khan, proprietor and other staffs of “Asian Colour Printing” whose hard work and co-operation have made almost “painless delivery” of this book Last but not least, I would like to express my gratitude to my wife and children for their untiring support, sacrifice and encouragement in preparing such a book of its kind ABM Abdullah Acknowledgments I had the opportunity to work with many skilled and perspicacious clinicians, from whom I have learned much of clinical medicine and still learning I pay my gratitude and heartiest respect to them I am also grateful to those patients whose clinical history and investigations are mentioned in this book I would like to express my humble respect and gratefulness to Prof Pran Gopal Datta, MBBS, MCPS, ACORL (Odessa), PhD (Kiev), MSc in Audiology (UK), FCPS, FRCS (Glasgow), Vice Chancellor, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh, whose valuable suggestions, continuous encouragement and support helped me to prepare this book I am also highly grateful to Dr Ahmed-Al-Muntasir-Niloy, who has worked hard checking the whole manuscript and making necessary corrections and modifications I also acknowledge the contribution of the following—my teachers, colleagues, doctors and students, who helped me by providing pictures, advice, corrections and many new clinical problems: • National Professor N Islam, IDA, DSc, FRCP, FRCPE, FCGP, FAS, Founder and Vice Chancellor, University of Science and Technology, Chittagong • National Professor MR Khan MBBS (Cal), DTM & H (Edin), DCH (Lond), FCPS (BD), FRCP (Edin), President, Shishu Sasthya Foundation, Director, Institute of Child Health & Shishu Sasthya Foundation Hospital, Visiting Professor, ICDDR,B • Prof MN Alam, FRCP (Glasgow), FCPS (BD), Ex-Professor of Medicine, BSMMU, Dhaka • Prof MA Zaman, MRCP (UK), FRCP (Glasgow), FRCP (London), Principal and Professor of Cardiology, Bangladesh Medical College, Dhaka • Prof Tofayel Ahmed, FCPS (BD), FCPS (Pak), FACP, FCCP (USA), MRCP, FRCP (Edin, Glasgow and Ireland), Ex-Professor and Chairman, Department of Medicine, BSMMU, Dhaka • Prof Quazi Deen Mohammad, MD (Neuro), FCPS (Med), Principal and Professor of Neurology, Dhaka Medical College, Dhaka • Prof MU Kabir Chowdhury, FRCP (Glasgow), Professor of Dermatology, Holy Family Red Crescent Medical College and Hospital, Dhaka 504 Case History and Data Interpretation in Medical Practice Spiro - 17 • FVC – 74.8% • FEV1 – 75.2% • FEV1/FVC – 83.33% This is a case of mild restrictive airway disease Spiro - 18 • FVC – 79.0% • FEV1 – 89.5% • FEV1/FVC – 98.44% • MMEF 75/25 – 65.9% This is a case of small airways obstruction Spiro - 19 • FVC – 49% • FEV1 – 23.9% • FEV1/FVC – 48.7% This is a case of severe obstructive airway disease Spiro - 20 • FVC – 68.3% • FEV1 – 81.8% • FEV1/FVC – 117.7% This is a case of moderate restrictive airway disease Spiro - 21 • FVC – 69.3% • FEV1 – 25.5% • FEV1/FVC – 36.6% This is a case of severe obstructive airway disease Spiro - 22 • FVC – 65.0% • FEV1 – 35.1% • FEV1/FVC – 54.1% This is a case of severe obstructive airway disease Answers—Spirometry 505 Spiro - 23(a) • FVC – 99.8% • FEV1 – 59.9% • FEV1/FVC – 60.9% This is a case of moderate obstructive airway disease Spiro - 23(b) (Reversibility test of the previous) FEV1: Before salbutamol inhalation is 1.34 L (59.9% predicted), which is consistent with moderate obstructive airway disease After 20 minutes of 200 μgm salbutamol inhalation shows, FEV1 is 1.93 L (87.6% predicted) So, there is 44% increased, which means positive reversibility (20% increase is needed to depict the reversibility as positive) So, it is consistent with bronchial asthma Spiro - 24(a) • FVC – 93.8% • FEV1 – 37.3% • FEV1/FVC – 39.7% This is a case of severe obstructive airway disease Spiro - 24(b) (Reversibility test of the previous) FEV1: Before salbutamol inhalation is 1.32 L (37.3% predicted), which is consistent with severe obstructive airway disease After 20 minutes of 200 μgm salbutamol inhalation, FEV1 is 1.32 L (37.3% predicted) So, FEV1 is not increased, which means negative reversibility (20% increase is needed to depict the reversibility as positive) So, it is consistent with COPD (also it may be found in severe persistant bronchial asthma) Spiro - 25 FEV1: Before salbutamol inhalation is 1.01 L (32% predicted), which is consistent with severe obstructive airway disease 506 Case History and Data Interpretation in Medical Practice After 20 minutes of 200 μgm salbutamol inhalation, FEV1 is 1.23 L (122% predicted) So, FEV1 is increased by 0.22 L and 90%, which means positive reversibility (20% increase is needed to depict the reversibility as positive) So, it is consistent with bronchial asthma Spiro - 26(a and b) FEV1: Before salbutamol inhalation is 0.8 L (35.1% predicted), which is consistent with severe obstructive airway disease After 20 minutes of 200 μgm salbutamol inhalation, FEV1 is 1.12 L So, FEV1 is increased by 0.32 L and 75%, which means positive reversibility So, it is consistent with bronchial asthma Answers Chapter V Pictures of Multiple Diseases “The trouble with doctors is not that they don’t know enough, but that they don’t see enough.” — Corrigan Answers—Pictures of Multiple Diseases 509 01: a Left-sided Horner’s syndrome b Partial third nerve palsy c To see the pupil, which is constricted, reacts to direct and consensual light 02: a Right-sided cervical lymphadenopathy b Cold abscess c FNAC or biopsy 03: a Palmar erythema, Dupuytren’s contracture b Chronic liver disease (Cirrhosis of liver) 04: a Short 4th metacarpal bone in right hand b Pseudohypoparathyroidism (Other causes of short 4th metacarpal bone are Turner’s syndrome, Noonan’s syndrome, sickle cell dactylitis, JIA, recurrent hand trauma) 05: a Leonine face b Leprometous leprosy c PKDL 06: a Erythematous rash b Dengue hemorrhagic fever 07: a Left-sided complete ptosis, right-sided partial ptosis b Myasthenia gravis 08: a Osteosarcoma b FNAC for histopathology 09 a b c and 10: Hyperextensibility of joint Steinburg sign Marfan’s syndrome 11: a Turner’s syndrome 510 Case History and Data Interpretation in Medical Practice b Buccal smear for karyotyping c Primary amenorrhea 12: a Relapsing polychondritis b Biopsy of the involved cartilage 13: a Periungul fibroma b Tuberous sclerosis c Epilepsy 14: a Rain drop pigmentation on back b Source of drinking water 15: a SLE, MCTD, dermatomyositis 16: a Post kala-azar dermal leishmaniasis (PKDL) 17: a Central retinal vein obstruction b Diabetes mellitus, hypertension 18: a Drum stick appearance b Interstitial lung disease (ILD) 19: a Wasting of muscles of both thighs b Proximal myopathy c Facio-scapulo-humeral musculodystrophy 20: a Pseudohypoparathyroidism b Short stature, mental retardation 21: a Pyoderma gangrenosum 22: a Multiple hypopigmented patch over chest and both upper arms, multiple small nodular lesion over dorsum of hand and fingers in right side Answers—Pictures of Multiple Diseases 511 b Lepromatous leprosy c Sensory test on hypopigmented patches 23: a Erythema nodosum b Sarcoidosis, primary pulmonary tuberculosis 24: a Abdominal striae, bilateral gynecomastia b Prolonged use of steroid (causing Cushing’s syndrome) 25: a Diffuse goiter, bilateral exophthalmos b Graves’ disease c Dermopathy 26: a Molluscum contagiosum b AIDS c Currettage 27: a Huge ascites, engorged superficial vein on abdomen, bilateral gynecomastia and wasting b Chronic liver disease (CLD) 28: a Leukonychia b Albumin deficiency (hypoalbuminemia) 29: a Drug reaction (Stevens-Johnson syndrome) 30: a Erythroderma b Psoriasis 31: a Left-sided complete ptosis with a scar mark over left side of head b Left-sided third cranial nerve palsy with possible intracranial surgery c Neoplastic lesion 32: a Chancre due to primary syphilis b Chancroid 512 Case History and Data Interpretation in Medical Practice 33: a Orf b A pox virus 34: a Raw beefy tongue and angular stomatitis b Deficiency of riboflavin, folic acid and iron 35 and 36: a Myotonia b Myotonic dystrophy 37: a Multiple nodules and cafe au lait spot b Neurofibromatosis type 38: a Puffy face with baggy eyelids b Hypothyroidism, superior vena caval obstruction 39: a Pes cavus b Friedreich’s ataxia 40: a Lupus pernio b Sarcoidosis 41: a Adenoma sebaceum b Tuberous sclerosis c Periungual fibroma (around nail base), Shagreen patch (cobble stone-like plaque at the base of spine on back) 42: a Cellulitis with foot ulcers b Blood sugar c Diabetic ulcer (Other causes are leprosy, syphilis, pyogenic infection) 43: a Pectus carinatum b Congenital, bronchial asthma from childhood, repeated respiratory tract infection, osteogenesis imperfecta, rickets, Marfan’s syndrome Answers—Pictures of Multiple Diseases 513 44: a Pectus excavatum b Causes are: • Congenital • Rickets • Marfan’s syndrome • Homocystinuria • Osteogenesis imperfecta • Ehlar-Danlos syndrome 45: a To see the flow of engorged veins b Superior vena caval obstruction, inferior vena caval obstruction 46: a Stevens-Johnson syndrome b Carbamazepine, sulflonamide, thiacetazone 47: a Knuckle pads on the fingers b Garrod’s patch 48: a Psoriatic plaque with knee joint swelling b Psoriatic arthritis 49: a Hyperkeratosis of palm, X-ray shows irregular narrowing of the lower end of esophagus suggestive of carcinoma esophagus b Tylosis 50: a Angioid streaks in retina b Pseudoxanthoma elasticum, Paget’s disease, acromegaly, sickle cell disease, Ehlar-Danlos syndrome (N.B Angioid streaks underlie the retinal vessel and cross the fundus radially from the optic disk They represent breaks/degeneration in the elastic tissue of Bruch’s membrane with resultant fibrosis) 51: a Pretibial myxedema b Graves’ disease 514 Case History and Data Interpretation in Medical Practice 52: a Diabetic cheiroarthropathy b Unknown 53: a Herpes zoster b Complications are secondary infection, generalized zoster, purpura fulminans (local purpura with necrosis) and postherpetic neuralgia Others are myelitis, meningoencephalitis, motor radiculopathy 54: a Guttate psoriasis 55: a Acute promyelocytic leukemia (with DIC) b Disseminated intravascular coagulation 56: a Behcet’s disease 57 and 58: a Budd-Chiari syndrome b Ultrasonogram of hepatobiliary system, CT scan (or MRI) of upper abdomen) 59: a Chronic tophaceous gout b Aspiration from tophus to see MSUM crystal under polarized microscope (crystal is needle-shaped, negatively birefringent) 60: a Pigmentation in surgical scar b Addison’s disease 61: a Deep jaundice, marked emaciation and pigmentation b Carcinoma head of the pancreas c CT-guided FNAC of pancreas 62: a Neurofibromatosis b Sarcomatous change (