Young boy with knee pain

A 15-year-old boy presented to the clinic complaining of right knee pain. He had the pain after a basketball game. The pain was mainly over the tibial tuberosity and did not radiate to other location. He did not have any past injury to his leg and there was no fever. He was well and had no significant past medical history.

On examination, there was tenderness over the right tibial tuberosity and there seemed to be a lump. There was some slight inflammation over the area. Otherwise, he was normal.

What is your diagnosis?

Behçet's Syndrome

Behçet's Syndrome is an immune-mediated multisystem disorder. Diagnosis is mainly clinical and based on the following diagnostic criteria:

• Recurrent oral ulceration + (2 of the following:)
• Recurrent genital ulceration
• Eye lesions (panuveitis, retinal vessel occlusions, optic neuritis, hypopyon uveitis)
• Skin lesions (folliculitis, erythema nodosum, acne-like exanthem)
• Pathergy test (nonspecific skin inflammatory reactivity to scratches or intradermal saline injection)

Other clinical features include arthritis, vein thrombosis & thrombophlebitis, mucosal ulcerations of GI tract. Neurologic involvement mainly has a serious prognosis.

Acute Glaucoma

Acute Angle-Closure Glaucoma occurs when the drainage of aqueous humor via the anterior chamber angle is blocked by the iris. People with shallow anterior chamber, either due to short axial length in hyperopia, or enlarged lens by development of cataract. Patients often complain of blurry vision and painful eye, with headache, nausea and vomiting.

Classical clinical features:

• mid-dilated pupil
• "deep-sea-green" pupil
• corneal oedema & injection
• circumcorneal redness
• abrupt rise of intraocular pressure

Acute glaucoma is treated as emergency. Medical treatment includes acetazolamide, beta blockers, pilocarpine, prostaglandin analogue, and alpha-2 adrenergic agonists. If medical treatment failed, laser iridectomy or surgical intervention is needed.

A man with repeated vomiting & haematemesis

A 50-year-old man presented with haematemesis a few hours ago. He had a few episodes of vomiting before the haematemesis. Before that, he attended a party and claimed that he drank a few cans of beer. However, he did not drink alcohol often, just a social drinker. He was not a smoker. He did not have any diarrhoea but he felt nauseous. There was no abdominal pain, no change in bowel movement. Family and past medical history was not significant. He did not take any drugs or painkiller recently.

On examination, the pulse rate was 90bpm, blood pressure was normal, no fever. Heart and lung examination were normal. There was no stigmata of chronic liver diseases. Abdominal palpation revealed no tenderness or guarding. There was no enlargement of liver and spleen.

1. What is the most likely diagnosis?

(Clue: repeated vomiting)

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An old lady with breathlessness

A 70-year-old lady present to the clinic complained of breathlessness on exertion since a month ago. There was no chest pain but she felt palpitation occasionally. On further questioning, she mentioned that she had to sleep on 2 pillows at night and might wake up suddenly due to shortness of breath. She also felt tired easily and noticed some loss of weight. Her appetite was not good nowadays. She had no significant past medical history and family history. She did not smoke nor take alcohol.

On examination, the patient appeared tired ad there was no sign of cyanosis, pallor or jaundice. Her pulse rate was 110bpm, rhythm was irregularly irregular, volume was strong. Her respiratory rate was normal. Blood pressure was 150/70mmHg. JVP was raised. Body temperature was normal.

Examination of the heart showed that her apex beat was slightly displaced to the lateral. On auscultation, there was a ejection systolic murmur. Auscultation of the lung revealed basal crepitation. Abdominal examination showed slight enlargement of the liver, no splenomegaly, kidney not palpable. Peripheral pulses were all palpable, symmetry and strong. There was mild pedal oedema.

ECG showed irregular rhythm with normal QRS complex. There was no pattern suggestive of previous myocardial infarction. Chest X-ray showed signs of pulmonary oedema and cardiomegaly. Blood test was normal except for elevated serum T3, T4 level.

1. What is the most likely clinical diagnosis?

2. What type of irregular rhythm was expected on ECG?

A restless patient

You were called to the surgical ward to see a restless patient. The patient was 50 years old and he underwent an appendectomy 2 days ago.

On examination, the patient was very restless, agitated and confused. There was tremor of the hand. His heart rate was 110 bpm, blood pressure was 150/90 mmHg. Heart & lung sound was normal. Neurological examination was normal.

His had no significant past medical history. He did not smoke, but drank 2-3 cups of wine everyday.

1. What is your clinical diagnosis?

2. Name the condition when an alcoholic patients with chronic thiamine deficiency develop CNS manisfestation.

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Man with bleeding per rectum

A 65-year-old man present to the emergency department with complaint of bleeding per rectum. He did not complain of diarrhoea or abdominal pain. He had a history of chronic constipation. His past medical history was otherwise non-significant.

On examination, he had mild fever of 37.9 degree Celcius. He had no signs of anaemia. Abdominal examination showed mild tenderness at lower abdomen. Rectal examination show maroon-coloured blood. The examination was otherwise normal.

1. Name 2 possible diagnoses.

(Clue: bleeding with no complaint of abdominal pain/diarrhoea)

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