A 14 year old male was brought to the emergency room by his mother by monkey6


A 14 year old male was brought to the emergency room by his mother

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									School of Natural Medicine
General Medicine 401
Assignment 1
Due Date: 4 May 2009
Total: 100 marks
Dr Kristian Leisegang

Case 1:

Sub-Total: 14 Marks

A 19 year old female, who is an arts and dance student, presents to your clinic. She is
complaining about breast tenderness, swelling & weight gain over since she finished
school a year previously.

On history taking, it is revealed that she smokes about 20 cigarettes per day, and had been
taking oral contraception (OCP’s) for the last 18 months (prescribed by her local general
practitioner on request by her mother). She reveals that she is currently sexually active.

Examination revealed that she has hypertension, with a blood pressure on 150/100. No
other abnormalities were detected.


   1.   What advice would you give to this patient? (4)
   2.   Would you refer to a cardiologist? Give a valid reason for your answer. (2)
   3.   List the major categories of oral contraceptive pills. (2)
   4.   What is the most likely cause of the main complaint in this case (1)
   5.   What contraceptive method would you recommend for this patient, and why? (5)

Case 2:

Sub-Total: 24 Marks

Mr Jackson (53 years old) presents in your clinic with a complaint of breathlessness on
exertion and ankle swelling of 3-months duration. Initially, when the problem began, he
had woken one night extremely short of breath and wheezing (A). He was also coughing
up pink frothy sputum (B). He said he had to get up and open the windows to ‘get some

Since that night he has had to sleep with 3 pillows (C) and has progressively become
more breathless on exertion. He has noticed that he is gaining weight and that both his
ankles are becoming progressively swollen (D).
He works as a sales representative and smokes and drinks heavily. Until recently, he had
been remarkably well.


   1. Give the medical term for symptoms described in A, B & C. (3)
   2. What is the most likely diagnosis? (1)
   3. Describe the pathology leading to the symptom described in C. (6)

On examination, the following signs were evident:

      Blood pressure 110/70
      A sinus gallop rhythm
      Raised jugular venous pulse (JVP) – 4 cm
      Displaced cardiac apex beat (to anterior maxillary line) with a left parasternal
      No murmers where heard
      Bilateral basal crepitations and signs of pleural effusions.
      He is grossly oedematous up to the thighs and he has ascites
      Hepatomegally with pulsation is evident

Further question:

   4. What do these physical signs each suggest, and based on these findings, what is
      the most likely aetiology of the diagnosis made in question 2. Support your
      answer with valid reasons. (14)

Case 3:

Sub-Total: 18 Marks

An eight year-old boy presents to his physician with a chief complaint of an earache,
fever and some degree of hearing loss. The patient's case history indicates a recent viral
upper respiratory tract infection.

During physical exam, the physician examines the patient with an otoscope and notes an
inflamed tympanic membrane that is bulging and opacified. Pneumatic otoscopy
confirms the presence of fluid in the middle ear. The patient is diagnosed with acute otitis
media, an infection of the mucoperiosteal lining of the middle ear which has a relatively
sudden onset and short duration.

   1. A major factor in the pathogenesis of otitis media is dysfunction of the auditory
      (old term: Eustachian) tubes. What is the function of the auditory tubes? (4)
   2. If the ventilatory function of the auditory (eustachian) tubes is compromised, air
      is resorbed by the middle ear and a negative pressure & anaerobic environment is
      created in the middle ear. The negative pressure may result in aspiration of
      nasopharyngeal contents, including bacteria, into the middle ear that then
      proliferate to cause otitis media. Which muscle opens the auditory (Eustachian)
      tube, and how? (2)
   3. What are possible complications to otitis media? (6)
   4. What would an infection of the outer ear be called? What anatomical
      features/structures protect the ear from injury? (6)

Case 4:

Sub-Total: 30 marks

A 46 year old male presented to your rooms with the following symptoms:

       High fever and rigors
       Malaise & anorexia
       Painful cough  dry at first, but is now productive with rust coloured sputum
       Nausea & vomiting
       Chest pain  described as sharp and localized to the 4th, 5th & 6th anterior
        intercostals on the right hand side

All these symptoms began 3 days ago.

On examination, you find the following:

       Patient appeared ill & confused
       Temperature: 39.3° C
       Blood pressure: 97/65 mmHg
       Pulse: 105 bpm regular & bounding
       Respiration rate: 25 bpm
       Possible central cyanosis
       Pleural rub & dull percussion note  4th, 5th & 6th intercostals spaces on right


   1. Very briefly, give a possible cause for the high fever. (2)
   2. Give 4 possible differential diagnoses for this case, in order of what you consider
      to be most likely. Give reasons for your answers based on explanations of the
      presenting signs & symptoms. You can also supply reasons that could possibly
      exclude each diagnosis (28)
Case 5:

Sub-Total: 14 marks

A 28 year old female presents to you complaining of increasing weight gain despite
attempts at dieting. She has also been trying to fall pregnant for 24 months, and has so far
not been successful. She complains of feeling excessively tired, and gets regular dizzy
spells & occasional blurry vision.

She also complains of excessive facial hair & acne, for which she is forced to spend
excessive money on facials and beautician treatments. The facial hair tends to be worse
on her upper lip and chin, and also on the midline of her stomach from the pubic region.
The acne is predominantly bilateral over the face and upper back.

On examination, you gain the following information:

       The patient appears depressed and over-weight
       Pulse: 82 bpm regular
       Respiration rate: 14 bpm regular
       Blood pressure: 185/110mmHg
       Weight: 109 Kg
       Height: 1.69m
       Signs of facial hair and acne on the face


   1. Calculate the patients BMI, and state which category she falls in. (2)
   2. State 3 endocrine causes of the condition in question 1. (3)
   3. What is the medical term for excess facial hair in a female? (1)
   4. To investigate the cause of excessive facial hair in a female, it is possible to ask
      for a random blood test that checks 5 specific parameters. What are they? (5)
   5. What is the medical term for irregular periods? (1)
   6. What condition is most likely based on the clinical features as presented above?

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