Year 3 History

Question 1

1. How has the pt. symptoms change w/time?
2. Are there any constitutional changes that you would counsel this pt for?
3. Is there any evidence of hereditary disorder in this family?
4. What life style adjustments might you recc to this pt?
5. Give 2 health risks when eating Western diet.

Answer 1

1. The symptoms have become more frequent & last for a longer duration.
2. Weight loss
3. There is evidence of breast cancer, at early age, in the female members of the family.
4. A. Resumption of walking or exercise to decrease weight
   B. Raising the head end of the bed
   C. Change to low fat, less spicy diet
5. A. Increased risk of type two diabetes
   B. Increased risk of heart disease
   C. Increased risk of obesity
   D. Increased risk of cancer

Question 2

1. What has been the pts reaction to her illness?
2. Give 3 reasons that cause the onset of the pt’s symptoms.
3. What is the most likely active ingredient in the neighbors tablets that gave relief to the pt?
4. Calculate the pt’s BMI.
5. Give 3 factors that place the pt. risk for the condition she has?
6. What type of condition was she diagnosed for at age of 44?

Answer 2

1. The pt became frightened by the severity of the pain.
2. Carrying heavy shopping bags, when walking upstairs, & walking longer distances/periods.
3. (Nitroglycerin): Glyceryl trinitrate
4. 32.05
5. (MI) DM, obesity, BMI >30, sedentary lifestyle
6. Type 2 diabetes

Question 3

1. What type of HTN is this pt. most likely to have?
2. T/F: Is it appropriate to diagnose this pt as Hypertensive on the basis of todays clinic readings?
3. What principle will be used for management of this pt’s HTN?
4. What 4 envt RF should you have asked this pt abt?
5. Is there a rltn b/w smoking & HTN, briefly explain your answer.
6. Does this pt have any Fx & occupational history that might be associated w her present complaints?
7. Explain the term secondary HTN & name 2 conditions that cause it.
8. What is “white-coat HTN”?

Answer 3

1. 90-95% of all cases of hypertension are “primary or essential” HTN. (+ This pt does not have any symptoms of endocrine/renal disease)
2. No. Diagnosing H.BP is based on the avg of 2 or more readings taken at each of 2 or more visits after an initial screening. (i.e. 3 visits in all with 2 readings each time. Measure BP in both arms, the arm w/higher value should be the reference arm for future measurement)
3. Repeated measurement of the patient’s BP showed it to be in the WHO’s defined range for HTN. The patient should receive life long pharmaco-therapy.
4. A. Obesity (not due to errors of measurement of the pt’s BP)
   B. Alcohol intake, (more than 6 units per day is a strong risk)
   C. Excess use of salt on food.
   D. Stress (acute stress & the pt’s mother may have been such a factor)
   E. Exercise//Coffee-intake//Smoking/2nd-hand smoking
5. Evidence shows that smokers have a slight increased risk – but it remains unclear whether this is a direct/indirect factor related to obesity that often follows smoking cessation.
6. Yes, Haya’s father is diabetic. Haya’s paternal uncle uncle was a hypertensive & died of a stroke at the age of 58 years. Heredity is one of the causes of H.BP, leading to CVD and stroke symptoms.She is worried about her mother’s condition and has also got stress at work keeping up with a lot of deadlines.
7. Secondary hypertension (secondary H.BP) is H.BP caused by another medical condition, ex: conditions that affect your kidneys, arteries, heart or endocrine system.
8. Some people experience H.BP only when they visit the doctor’s office. This condition is called “white- coat hypertension.” OR Falsely raised BP bcuz of stress from medical staff/hospital

Question 4

1. What is the cause of pts breathlessness at night?
2. Explain why her sputum changed color.
3. What 2 heart conditions might individually/together cause her problem?
4. Why do you think she has poor hearing in one ear?
5. What modifications of her life style would you recommend?
6. Is this pt overweight, explain your answer?

Answer 4

1. Pulmonary oedema (1) resulting from left sided heart failure (2). The back pressure (3) is transmitted to the pulmonary venules draining the alveolar capillaries (4) thereby causing increased volumes of fluid to be filtered into the alveolar tissue (5) that exceed the lymph drainage capacity (6). The pressure balance is upset by the patient lying down (7).
2. Tissue fluid that escapes into the alveoli is cleared from the lungs as frothy white sputum (1) and when some of the alveoli breakdown due to this pulmonary oedema small amounts of blood cause the sputum to become pink from blood (2).
3. The pt has been diagnosed with a valve disease (aortic or mitral valves), but also has major risk factors for atherosclerosis which would lead to CAD. Both could individually or in combination cause CHF (left-sided HF).
4. Chronic left ear infections as a child (although rather unusual today), quite likely fifty years ago in Kuwait when patient was a child.
5. The patient shall stop smoking (1), start taking regular exercise (2), reduce or omit added salt with his/her food (3), consider omitting all alcohol (4).
6. She has had constant weight of 89kg at 164 cm height for 20 yrs, making her BMI 27, which is overweight. However,the recent weight gain, 5 kilos in 2-3 weeks, is not over eating or a sudden change in life style, but due to accumulation in fluid

Question 5

1. Give pt’s 2 predisposing factors that lead to her present problem?
2. Name the likely organism that caused the initial pathology?
3. Briefly explain the pathogenesis behind pt’s problem?
4. What precipitating factor is making her problem worse?
5. Explain the mechanism of this patient’s dyspnoea?
6. What could be the reason for palpitations in the patient?
7. What could be the purring feeling the patient has over chest?

Answer 5

1. i. History of sore throat followed by arthritis when pt was 10 y/o points to an attack of rheumatic fever in past
   ii. Non-compliance to penicillin prophylaxis
2. Group A beta-haemolytic streptococcus
3. Streptococcus induced autoimmunity is believed to be the mechanism resulting in rheumatic process. Several streptococcal antigens cross react with cardiac and other tissues.
4. Pregnancy
5. Dyspnoea results from pulmonary venous congestion as the result of mitral valve disease. Fluid is driven out of pulmonary capillaries into the interstitium, which decreases the compliance and gas exchange of lung resulting in dyspnoea.
6. Atrial fibrillation
7. The patient has thrill, a palpable murmur

Question 6

1. What are the presenting symptoms of the pt?
2. What is the commonest cause of “sore throat”?
3. The pt took Panadol to lower her temp. What is the active ingredient in Panadol & by what mechanism does this tablet reduce the body temp?
4. What is the likely diagnosis & what is the condition commonly known as?
   5.What is the commonest complication of influenza?
5. Why is the pt having body aches & pain?

Answer 6

1. Sore throat, Runny nose, Cough & Fever
2. Most sore throats, such as those that accompany a cold or the flu, are caused by viral infections (Adenovirus infection)
3. Paracetamol is the active ing in Panadol & it reduces fever by selectively inhibiting COX 3, an enzyme found in the brain & SC.
4. The likely diagnosis in this case is Influenza which is commonly known as “Flu”.
5. Pneumonia
6. Inflammation of the muscles of the body (myositis) can occur in influenza which gives rise to this aches & pain.
   The body’s first response to help fight an infection is to release of substances called cytokines, which may be responsible for producing many of the symptoms like fever, loss of appetite and muscle aches & pains.

Question 7

1. What evidence is there to support an infective process, name 3 pieces of evidence.
2. Does the pt have any past medical history that might be associated w her present compliant?
3. Which side the pt is experiencing the chest pain & what aggravates it?
4. What may be the cause of the chest pain in this pt?
5. Which condition is. Diagnosed in this pt 8 yrs back & mention the medication she is taking for it.
6. What causes pneumonia?

Answer 7

1. (i) Fever, (ii) Chills and night sweats, and (iii) Yellowish green sputum
2. The history of an episode of bronchitis and numerous episodes of cough and sinusitis might be associated with her present complaints.
3. Patient is experiencing left sided chest pain which gets worse on coughing or deep breathing
4. The cause of chest pain in this patient may be because of inflammation to the lining of the
   lungs (Pleura)
5. Patient is diagnosed of Type I Diabetes Mellitus 8 years back and she is on Injection Insulin.
6. Pneumonia is caused by many factors such as infection with bacteria, viruses or fungus and also due to breathing in (aspirating) food, liquid, chemicals and dust.

Question 8

1. Name some air allergens that can cause URT symptoms.
2. Does this pt have any occupational hx & family hx associated w her symptoms?
3. Over past 3 yrs, how does pt have symptomatic control of epi of wheezing & SOB?
4. By what mechanism does B-adrenergic agonist act to relieve the epi of wheezing?
5. What is the major SE of inhaled beta-adrenergic agonist?
6. When is her cough worse? What is the underlying pathophysiology of the cough?
7. Which respiratory structure(s) become narrowed during an asthmatic attack?

Answer 8

1. Grass pollen, house dust mites, molds, waste from cockroaches & animal dander (from the skin, hair, or feather of animals)
2. Pt gives hx of working as a tech in lab where she has to work w animals & this might be the stimuli for her repeated epi over the past 3 yrs. The pt’s sister is having asthma & her father is having allergic rhinitis.
3. Over the past 3 yrs, pt is on metered dose inhaler of beta-adrenergic agonist
4. Beta-adrenergic agonists relax smooth muscles & cause bronchodilation
5. tremors
6. The cough is nonproductive & worse at night. During an epi, inflamed airways react to triggers such as smoke, dust, or pollen; the airways narrows & produce excess mucus
7. Bronchioles react to triggers & become narrowed during an attack

Question 9

1. For how long is the pt not well & what are her presenting complaints?
2. What is the frequency of attacks in this case & how long these attacks lasted?
3. What were the factors which worsened pt’s attacks?
4. What could be the reason behind the pt snoring & keeping her mouth open while sleeping?
5. Define tonsilitis.
6. What is the function of tonsil in the body?
7. Locate the part in the following fig (pic in answers)

Answer 9

1. Pt is not well for past 1 week & presents w fever, cold & runny nose, pain in the throat & cough.
2. Pt would get these attacks once every 3-4 months & each attack would be there for abt 1 week.
3. Cold food & cold drinks
4. Pt’s adenoids are infected along w tonsil which narrows the airway & reduce the flow of air into & out of lungs which leads to snoring & keeping her mouth open during sleep
5. Tonsillitis is an inflammation of the tonsils in the mouth
6. They produce antibodies that fight nose & throat infections. They confine the infection to the throat, rather than allowing it to spread to the neck or bloodstream.
7. Tonsils & Adenoids

Question 10

1. Does the pt have past medical history that might be associated w present complaint?
2. Does the pt have any habits that aggravated his resp condition?
3. What do you understand by “bronchiectasis”?
4. What tx did the pt recieve for it?
5. Name any 2 conditions that can cause foul smelling sputum other than bronchiectasis?
6. What is the evidence of a chronic debilitating condition in him?

Answer 10

1. Hx of pneumonia
2. Smoking & keeping birds as pets
3. Bronchiectasis is a congenital or acquired disorder of large bronchi, characterized by permanent, abnormal dilation & destruction of bronchial walls.
   destruction of smooth muscle & elastic tissue by inflammation, stemming from persistent/severe necrotizing infections, leading to permanent dilation of bronchi & bronchioles
4. He received intensive chest PT, postural drainage, bronchodilators & IV antibacterial therapy
5. Lung abscess & gangrene of lung
6. Loss of appetite, weight loss, malaise

Question 11

1.Does the pt complain of fever & describe the type of fever?
2. What is the medical term given to Blood stained mucous?
3. What happened to Patient’s husband in Nov 2006?
4. What is the primary cause of Tuberculosis?
5. How does this TB germ spread?
6. What is the commonest source of TB germ & what could be the likely source of infection for this pt?
7. Name the vaccine given to prevent childhood TB.

Answer 11

1. Yes, the pt complained of fever & there is an evening rise of body temp associated w chills
2. Hemoptysis
3. Pt’s husband was diagnosed of having pulmonary TB in Nov 2006
4. Mycobacterium tuberculosis
5. TB germ is carried on droplets in the air, and can enter the body thru the airway. A person w/active pulmonary TB can spread the disease by coughing or sneezing
6. Sputum of an infected individual is the commonest source of this organism. Pt must have contracted this infection from her husband before his tx started.
7. BCG vaccine which is given to prevent childhood TB disease

Question 12

1. Name the medical term&
   used for SOB?
2. When a pt complains abt breathlessness,
   what additional info you will ask abt the symptom?
3. State 4 respiratory conditions
   that can cause clubbing?
4. What is cyanosis & underlying pathophysiology for cyanosis?
5. What tx did pt receive for his problem?

Answer 12

1. Dyspnea
2. How short of breath is the pt? When does it come? Present at rest/exertion? What degree of exertion is necessary to produce it? Does he have attacks of breathlessness at night? Does he have to sit up or can he sleep lying down?
3. Bronchiectasis, lung abscess, bronchogenic carcinoma, pulmonary fibrosis
4. Bluish discoloration of skin & mucus membrane due to presence of excess of reduced Hb in blood is called cyanosis
5. He was treated w/steroids & oxygen inhalation

Question 13

1. What is the main complaint in this pt?
2. What did u elicit on social hx with regards to smoking & do u think this is clinically relevant to the pt’s history
3. What was the cause of death of this pt’s (1) father (2) mother?
4. What 4 features are suggestive of malignancy in this patient?
5. What do you think why the voice has been changed to hoarse voice in this patient?

Answer 13

1. This pt complained mainly about coughing up blood stained mucous
2. Pt has smoked for 42 yrs a pack of cigarettes everyday & he started smoking at the age of 16 yrs.
   This history clinically relevant to the pt’s history bcuz Cigarette smoking is a predisposing risk factor for Carcinoma of bronchus.
3. (1) Pneumonia (2) Breast cancer
4. (1) Coughing up blood stained mucous
   (2) Loss of weight
   (3) Hoarseness
   (4) Poor response to several courses antibiotics.
5. The local spread of cancer cells leading to involvement of recurrent laryngeal nerve is responsible for the change in voice in this pt

Question 14

1. Mention abt 2 presenting complaints of the pt.
2. Name the bones in the palm of the hand, bone shafts & joints in the hand against the arrows as shown in the figure (in the ans)
3. What medical term is used to describe the involvement of more than one joint?
4. What is the cause of the swelling of the wrist & finger joints in this pt?
5. How will you diff b/w RA & OA? (any 4 pts)

Answer 14

1. Pain in the small joints of both hands & wrist joint
   Swelling in the fingers & both wrists
   Stiffness in the wrist joints & finger joints
   Tingling numbness in right hand
2. (From proximal > distal) carpometacarpal joint - metacarpals - metcarpophalangeal joint - proximal phalanx - interphalangeal joints - middle phalanx - interphalangeal joints - distal phalanx
3. Polyarthritis
4. The 1st stage of the disease involves inflammation in the lining of the joint (synovium), which causes mild-to-moderate pain, warmth, redness, & stiffness in and around the joint
   In the 2nd stage of RA, rapid cell division and growth occurs in the synovium (called pannus), causing thickening w/in the joint
   When the lining of the joint becomes inflamed, it gives off more fluid & the joint becomes swollen
5. TABLE BELOW

Question 15

1. Write 3 major symptoms that the pt had in relation to his right shoulder?
2. Describe 2 aggravating & 2 relieving factors of shoulder pain experienced?
3. Write 3 modalities of tx that the pt received in past 2 yrs? Which tx does the pt keep postponing & why?
4. What is rotator cuff? Which structures constitute the rotator cuff of the shoulder joint?
5. How many bones & joints make up the shoulder?

Answer 15

1. Pain of right shoulder, extending down the sides of upper third of the arm
   Weakness of right shoulder
   Thinning of the muscles about the shoulder Crackling sensation w/in the shoulder
   Pain that disturbs his sleep when he turns on affected side
2. Aggravated by 1) mvmnt, esp over head moments, 2) cold weather
   Relieved by 1) anti-inflammatory drugs, 2) local heat, or 3) cold
3. He has taken 1) anti-inflammatory drugs, 2) steroid injection, 3) PT, 4) electrical stimulation
   Surgical correction is the tx modality he is postponing bcuz of lack of time due to his busy schedule
4. The rotator cuff is an anatmoical term given to the grp of muscles & their tendons that act to stabilize the shoulder
   The 4 muscles of the cuff are supraspinatus, infraspinatus, subscapularis, & teres minor
5. 3 bones: 1) humerus 2) scapula 3) clavicle
   3 joints: 1) Glenohumeral 2) Acromioclavicular 3) Sternoclavicular

Question 16

1. What 3 major symptoms does the pt have in relation to his left hip?
   2.