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)

*Answers in comment*

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.

*Answers in comment*

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)

*Answers in comment*

Woman with yellow eyes and skin

A 60-year-old woman present to the clinic with yellowish eye and skin. She also complained of itchiness of skin. She also mentioned that her urine was tea-coloured. From her history, there were lost of appetite and weight loss. There was no significant past medical history.

On examination, there were scratch marks on her skin. The nails were noted to be shining. Her heart rate was 58bpm. Examination of the abdomen revealed an enlarged mass at the right upper quadrant. There was no tenderness.

1. What is the clinical diagnosis?

(clue: presentation, heart rate, clinical findings)

2. What is the name of the sign found in abdominal examination?

*Answers in comment*