Ebook Case history and data interpretation in medical practice: Part 2

I
Case History and
Data Interpretation
(For answers: See page 317-484)

“It is impossible for anyone to find the correct function
of any part unless he is perfectly acquainted with the
action of the whole instrument”
— Galen


“It is much more important to know what sort of
patient has a disease than what
sort of disease a patient has”
— Sir William Osler


Case History and Data Interpretation

3

Case No. 001
A man of 63 years presented with the complaints of weakness,
dizziness, lethargy, palpitation, breathlessness on mild exertion and
weight loss for six months.
On examination, appearance – pigmented, anemia – moderate,
jaundice – nil, edema – mild, pitting. BP – 90/60 mm Hg, pulse –
110/min.
No other physical findings.
Investigations
• Urine

• Full blood count

•

PBF

•
•
•
•
•
•
•
•

Reticulocyte count
Bilirubin
SGPT
Alk. phosphatase
Serum creatinine
S. iron
TIBC
S. ferritin

- Protein (+).
- Hb – 7.2 gm/dl, WBC – 4,000/cmm,
poly – 55%, lympho – 45%,
platelets – 1,90,000/cmm,
ESR – 52 mm in 1st hr.
- Microcytic, hypochromic,

few normocytic and normochromic.
- 0.8% (normal 0.2 to 2%).
- 28 μmol/L (normal 2 to 17).
- 39 IU/L (normal 10 to 40).
- 110 IU/L (normal 25 to 100).
- 1.3 mg/dl (normal 0.5 to 1.13).
- 45 μmol/L (normal 4 to 30).
- 88 μmol/L (normal 45 to 72).
- 550 μgm/L (normal 20 to 300).

Questions
a. What is the likely diagnosis?
b. Mention 1 investigation to confirm your diagnosis.
c. Suggest 1 single therapeutic advice to the patient.

Case No. 002
A 27-year-old female with eight months pregnancy is referred for
jaundice. She is admitted in the hospital with suspected pre-eclampsia.
On examination, the patient is ill looking, anemia – moderate,
jaundice – moderate, edema – mild and pitting. BP – 150/105 mm Hg.
Investigations
• Urine
• Full blood count

- Protein (++).
- Hb – 8.2 gm/dl, WBC – 15,000/cmm,


4

•
•
•
•
•

Case History and Data Interpretation in Medical Practice

Bilirubin
SGPT
Alk. phosphatase
Serum creatinine
S. electrolytes

-

poly – 75%, lympho – 25%,
platelets – 90,000/cmm,
ESR – 62 mm in 1st hr.
118 μmol/L (normal 2 to 17).
99 IU/L (normal 5 to 40).
290 IU/L (normal 20 to 100).
1.3 mg/dl (normal 0.5 to 1.13).
Sodium 138 mmol/L.
Chloride 100 mmol/L.
Potassium 4.6 mmol/L.
Bicarbonate 23 mmol/L.

Questions
a. What is your diagnosis?

b. What 2 further investigations would you suggest?
c. What treatment would you give?

Case No. 003
A 49-year-old lady, nondiabetic and nonhypertensive, presented with
frequent attacks of dizziness, vertigo, palpitation, weakness and
sweating for ten months. Initially, these symptoms were present in
the morning after waking from sleep and relieved by breakfast. For
the last six months, these symptoms are more frequent any time of
the day and relieved by taking food. Recently, the patient has gained
weight of about 12 kg.
On examination, the patient looks obese, multiple linear striae are
present. BP – 130/80 mm Hg, pulse – 84/min.
Examinations of other systems reveal no abnormality.
Questions
a. What is
b. Suggest
c. Suggest
d. Suggest

your diagnosis?
1 alternative diagnosis.
2 other causes of such case.
3 investigations.

Case No. 004
A 16-year-old school student has been suffering from weakness,
polyuria, nocturia and cramps in legs for three years. No history of
diarrhea or vomiting.

Case History and Data Interpretation

5

On examination, the patient looks emaciated, moderately anemic.
BP – 110/75 mm Hg, pulse – 76/min. muscle power and tone –
diminished. all reflexes – diminished. Other systems reveal no
abnormality.
Investigations
• Full blood count

•
•
•
•

RBS
Urine
Serum creatinine
S. electrolytes

•
•

USG of abdomen
Chest X-ray

- Hb – 10.2 gm/dl, WBC – 10,000/cmm,
poly – 65%, lympho – 35%,

platelets – 2,70,000/cmm,
ESR – 42 mm in 1st hr.
- 6.1 mmol/L.
- Protein (+).
- 1.1 mg/dl.
- Sodium 141 mmol/L.
Chloride 100 mmol/L.
Potassium 2.6 mmol/L.
Bicarbonate 32 mmol/L.
- Normal.
- Normal.

Questions
a. What is your diagnosis?
b. Suggest 3 further investigations.
c. Suggest 2 differential diagnoses.

Case No. 005
A 35-year-old receptionist is admitted in the surgical unit with severe
abdominal pain, frequent vomiting and constipation for nine days. On
inquiry, it was found that she had similar attack many times since
10 years and she was admitted four times in the hospital. Five years back,
appendicectomy was done, but her symptoms did not improve. For the
last six months, she is complaining of insomnia, anxiety and confusion.
On examination, BP – 160/115 mm Hg, pulse – 124/min, abdomen –
diffuse tenderness. No other physical findings.
Investigations
• Full blood count

- Hb – 12.2 gm/dl, WBC – 13,900/cmm,

poly – 62%, lympho – 35%,
eosinophil – 3%,
platelets – 2,90,000/cmm,
ESR – 42 mm in 1st hr.


6

Case History and Data Interpretation in Medical Practice

•
•
•
•

RBS
Urine R/E
Serum creatinine
S. electrolytes

-

•
•
•
•
•

S. bilirubin
SGPT

USG of abdomen
X-ray chest
Barium meal and
follow through
Barium enema

-

•

7.1 mmol/L.
Normal.
1.2 mg/dl.
Sodium 131 mmol/L.
Chloride 98 mmol/L.
Potassium 4.6 mmol/L.
Bicarbonate 26 mmol/L.
55 μmol/L (normal 2 to 17).
96 IU/L (normal 10 to 40).
Normal.
Normal.
Normal.

- Normal.

Questions
a. What is your diagnosis?
b. List 3 investigations for your diagnosis.

Case No. 006

A 30-year-old housewife, living in a slum area, is complaining of
severe pain in lower abdomen, high grade, continuous fever, burning
micturition and purulent vaginal discharge for two days. She was
given oral antibiotic and pain killer (indomethacin) as suppository.
After three days, she is hospitalized, because of severe pain in right
hypochondrium, which radiates to the right shoulder, associated with
vomiting and dry cough.
On examination, looks ill, dehydrated. BP – 90/60 mm Hg, pulse –
120/min, temperature – 38.9°C.
Liver – enlarged, 2 cm, tender. Hepatic rub – present.
Stony dull in right lower chest with absent breath sound.
Questions
a. What is your diagnosis?
b. Suggest 2 differential diagnoses.
c. Suggest 4 investigations.

Case No. 007
A 39-year-old school teacher, presented with low grade continuous
fever, pain in multiple joints, weight loss and dry cough for six months.


Case History and Data Interpretation

7

For the last three months, she is also complaining of swelling of both
parotid gland and few red lesions in leg.
On examination, patient is ill looking and emaciated, BP –
95/60 mm Hg, pulse – 106/min, temperature – 37.8°C.
Both parotid glands are enlarged, one right supraclavicular lymph

nodes are palpable and non-tender. Spleen – just palpable.
Questions
a. Suggest 4 differential diagnoses.
b. What is the likely diagnosis?
c. Suggest 5 investigations.

Case No. 008
A 20-year-old student, presented with gross hematuria, 3 days after sore
throat, fever and headache. There is no significant past medical history.
On examination, no abnormality in general examination. Throatcongested with enlarged tonsils. BP – 110/70 mm Hg, pulse – 80/min,
temperature – 38.2°C.
Examination of other systems reveal no abnormality.
Investigations
• Full blood count

•

Urine microscopy

•
•
•
•

Urinary protein
Urea
Creatinine
S. electrolytes

•

•
•
•

Creatinine clearance
Throat swab
Chest X-ray
USG of abdomen

- Hb – 14.3 gm/dl, WBC – 10,900/cmm,
poly – 62%, lympho – 38%,
platelets – 3,95,000/cmm,
ESR – 55 mm in 1st hr.
- red cell casts (+++) and
granular casts (+++).
- 0.16 gm/24 hrs.
- 3.6 mmol/L.
- 1.2 mg/dl.
- Sodium 138 mmol/L.
Potassium 4.2 mmol/L.
Bicarbonate 26 mmol/L.
Chloride 101 mmol/L.
- 68 ml/min (normal 98 to 168).
- no growth.
- Normal.
- Cortex and medulla of both
kidneys are irregular.


8

Case History and Data Interpretation in Medical Practice

Questions
a. What is the most likely diagnosis?
b. Suggest 3 diagnostically helpful investigations.
c. Mention 1 alternative diagnosis.

Case No. 009
A 31-years-old housewife has been suffering from occasional loose
motion, weight loss, weakness, palpitation and insomnia for 6 months.
Three days before admission, she has been suffering from high grade,
continuous fever, cough with yellow sputum, right sided chest pain,
nausea and vomiting. On the 3rd day, she feels drowsiness, dizziness,
followed by confusion, incoherent talk and delirium.
On examination, looks very anxious and emaciated. Anemia-mild,
few submandibular lymph nodes palpable, small smooth goiter is
present, temperature – 40°C, BP – 160/70 mm Hg, pulse – 140/min,
irregularly irregular
Heart – systolic murmur in pulmonary area.
Investigations
• Full blood count

•

Chest X-ray

•
•
•

ECG
RBS
S. electrolytes

•
•

Urea
Creatinine

- Hb – 10.5 gm/dl, WBC – 23,540/cmm,
poly – 88%, lympho – 12%,
platelets – 1,80,000/cmm,
ESR – 49 mm in 1st hr.
- Homogeneous opacity in the
left upper zone.
- Atrial fibrillation.
- 12.1 mmol/L.
- Sodium 128 mmol/L.
Potassium 4.1 mmol/L.
Bicarbonate 21.8 mmol/L.
Chloride 105 mmol/L.
- 45 mg/dl.
- 1.2 mg/dl.

Questions
a. What is the likely diagnosis?
b. What investigation should be done to confirm your diagnosis?

Case History and Data Interpretation

9

Case No. 010
A 70-year-old lady is suffering from fever, frequency of micturition and
feeling unwell for 10 days. She is hospitalized, because of confusion,
drowsiness, followed by unconsciousness. There was no history of
diabetes mellitus, hypertension or any drug intake.
On examination, the patient is semiconscious, response to painful
stimulus. tongue – dry, skin turgor – reduced, BP – 90/60 mm Hg,
pulse – 110/min, low volume. Temperature – 39.2ºC.
Neck rigidity – slightly present. Plantar- extensor on both sides.
Lower abdomen – very tender.
Investigations
• Full blood count

•

S. electrolytes

•
•
•
•
•
•

Bilirubin

SGPT
Alk. phosphatase
Serum creatinine
Serum urea
Urine

•
•

Chest X-ray
CT scan of brain

- Hb – 11.2 gm/dl, WBC – 17,000/cmm,
poly – 85%, lympho – 15%,
platelets – 2,10,000/cmm,
ESR – 12 mm in 1st hr.
- Sodium 158 mmol/L.
Chloride 110 mmol/L.
Potassium 4.6 mmol/L.
Bicarbonate 19 mmol/L.
- 18 μmol/L.
- 29 IU/L.
- 90 IU/L.
- 1.4 mg/dl.
- 38 mg/dl.
- Plenty of pus cells, albumin (++),
glucose (+++).
- Normal.
- Diffuse age-related cerebral atrophy.

Questions
a. What is the likely diagnosis?
b. Suggest 4 investigations.
c. What immediate therapeutic measures would you start?

Case No. 011
A 59-year-old man, smoker, diabetic, had an attack of acute myocardial
infarction. During recovery, he developed sudden blindness.


10

Case History and Data Interpretation in Medical Practice

On examination, there is no significant finding on general
examination. BP – 100/60 mm Hg, pulse – 82/min, irregular.
Heart – pansystolic murmur in mitral area. Lungs and abdomen – no
abnormality.
Pupil – normal in size and shape, equally reactive to light and
accommodation. No other neurological finding. Fundoscopy – normal.
Questions
a. Where is the site of lesion?
b. What is the likely cause?
c. Suggest 1 investigation to confirm your diagnosis.
d. What is the prognosis?
e. Mention 2 causes of murmur.

Case No. 012
A 29-year-old clerk is hospitalized with the complaints of high grade,
continuous fever, polyarthritis involving all the joints, generalized

bodyache, right sided chest pain, abdominal pain, nausea and occasional
vomiting for 8 weeks. She also lost weight about 3 kg within this
period. There is no history of cough, chest pain or hemoptysis.
On examination, looks unwell, anemia – moderate, cervical and
inguinal lymphadenopathy, which are soft, discrete and non-tender.
Liver – enlarged, 2 cm, non-tender. Spleen – just palpable.
Pleural rub – present on right lower chest. Abdomen – diffusely
tender and slightly rigid. Both knee joints – swollen and tender.
Cervical spine – painful restricted movement. Left shoulder and both
wrist joints are tender.
Investigations
• Full blood count

•
•
•
•
•
•

- Hb – 8.5 gm/dl, WBC – 33, 540/cmm,
poly – 81%, lympho – 19%,
platelets – 1,88,000/cmm,
ESR – 138 mm in 1st hr.
Chest X-ray
- Consolidation in right lower zone
with small pleural effusion on left.
RBS
- 8.1 mmol/L.
Blood and urine C/S - No growth.

RA test and ANA
- Negative.
CRP
- 54 g/L (normal <10).
ASO titer
- 400 IU/L.


11

Case History and Data Interpretation
•
•
•

Urea
Creatinine
USG of abdomen

- 45 mg/dl.
- 1.2 mg/dl.
- Hepatosplenomegaly, mild
ascites and paraaortic
lymphadenopathy.

Questions
a. What further history will you take from the patient?
b. What diagnosis would you consider first?
c. Suggest 2 differential diagnoses.
d. Suggest 3 investigations.

Case No. 013
An 18-year-old girl presented with the complaints of irregular
menstruation and hirsutism. The problem is present for 4 years, but
becoming worse for the last 1 year, for which she was always depressed.
Investigations

Result

Normal value

1.
2.
3.
4.
5.
6.

1.8 mIU/L
295 u/L
19.3 u/L
21.1 u/L
34.9 u/L
13 nmol/L
272 nmol/L.

< 5.5 mIU/L
<400 u/L
1 to 13 u/L
4 to 13 u/L

1 to 12 u/L
1 to 12 nmol/L

TSH
Prolactin
LH
FSH
Testosterone
17-hydroxyprogesterone and
30 min. after synacthen injection

Questions
a. What is the diagnosis?
b. Suggest 1 alternative diagnosis.
c. What test should be done to differentiate between these two?
d. What is the treatment?
e. Suggest 2 investigations for your diagnosis.

Case No. 014
A young patient is hospitalized with the complaints of high fever,
severe headache, repeated vomiting and exhaustion for 6 days.
One day before admission, he noticed some red spots in different
parts of the body.
On examination, the patient looks toxic, anemia – mild, jaundice –
nil.


12

Case History and Data Interpretation in Medical Practice

Temperature – 104°F, BP – 90/60 mm Hg. pulse – 110/min.
Few petechial rash in trunk and some red spots in different parts
of the body.
Neck rigidity – slight. Kernig’s sign – absent.
Fundoscopy – normal.
No other physical findings.
Investigations
• Full blood count

•
•
•

Urine
Chest X-ray
S. electrolytes

•
•

Blood glucose
ECG

- Hb – 11.9 gm/dl, WBC – 26,000/cmm,
poly – 87%, lympho – 13%,
ESR – 40 mm in 1st hr,
platelets – 80,000/cmm.
- Few pus cells, protein (+).
- Normal.

- Sodium 140 mmol/L.
Chloride 100 mmol/L.
Potassium 3.9 mmol/L.
bicarbonate 22 mmol/L.
- 3.2 mmol/L.
- Sinus tachycardia.

Questions
a. What is the likely diagnosis?
b. Suggest 1 alternative diagnosis.
c. Suggest 3 investigations.
d. Mention 1 confirmatory test for your diagnosis.
e. Suggest 1 further investigation.

Case No. 015
A 59-year-old, retired male, was suffering from chronic liver disease
with hepatitis B infection for 3 years. For the last one month, he
has been suffering from weakness, anorexia, abdominal distension and
jaundice. He was on diuretics and vitamins.
For the last 9 days, he was hospitalized because of increasing
abdominal distension, diffuse abdominal pain, scanty urine and
continuous fever.
On examination, the patient is pale, anemia – moderate, jaundice –
mild, BP – 105/60 mm Hg, pulse – 70/min. ascites – huge, spleen – just
palpable, abdomen – mild diffuse tenderness present.


Case History and Data Interpretation
Investigations
• Full blood count

•
•
•
•
•
•
•

Chest X-ray
ECG
RBS
Urine
Urea
Creatinine
USG of abdomen

13

- Hb – 8.5 gm/dl,
WBC – 13,540/cmm, poly – 84%,
lympho – 13%, eosinophil – 3%,
platelets – 88,000/cmm,
ESR – 88 mm in 1st hr.
- Bilateral pleural effusion.
- Normal.
- 8.1 mmol/L.
- A few pus cells.
- 25 mg/dl.
- 1.2 mg/dl.

- Liver – small with high,
coarse echogenicity,
splenomegaly
and huge ascites.

Questions
a. What is the likely diagnosis?
b. What single investigation would you suggest?
c. Mention 1 specific treatment may be required in such case.

Case No. 016
A 26-year-old young lady developed nausea, vomiting and severe
abdominal pain for one week. She is also complaining of pain in both
hip joints for the same duration. There is no history of trauma.
She has been suffering from SLE for 5 years, well controlled with
steroid and chloroquine.
On examination, looks – pale, anemia – moderate, jaundice –
absent.
Liver – just palpable, non-tender, spleen – enlarged, 1 cm.
Abdomen – diffusely tender.
Investigations
• Full blood count
•

Urine

•

Serum creatinine

- Hb – 8.2 gm/dl, WBC – 10,100/cmm,
poly – 76%, lympho – 24%
ESR – 90 mm in 1st hr.
- Plenty of pus cells, albumin (++),
glucose (+).
- 1.1 mg/dl.


14

Case History and Data Interpretation in Medical Practice

•
•
•
•

Serum urea
Chest X-ray
Plain X-ray abdomen
Electrolytes

•
•
•

Bilirubin
SGPT
Alk. phosphatase

-

38 mg/dl.
normal.
Subacute intestinal obstruction.
Sodium 129 mmol/L.
Chloride 98 mmol/L.
Potassium 4.6 mmol/L.
Bicarbonate 23 mmol/L.
- 17 μmol/L.
- 35 IU/L.
- 93 IU/L.

Questions
a. What is the diagnosis?
b. What is the cause of her hip pain?
c. Suggest 1 definite investigation for her hip pain.

Case No. 017
A woman of 62 years was admitted in the hospital with the history of
confusion, incoherent talk, difficulty in breathing and incontinence of
urine for two days. Six hours after admission, she became unconscious.
5 days before this, there was a history of fall with fracture of neck
of right femur.
On examination, the patient looks unwell, responds to painful
stimuli, BP – 105/65 mm Hg, pulse – 58/min, neck rigidity – absent.
plantar – extensor on both sides. Examination of other systems reveal
no abnormality.
Investigations
• Full blood count

•
•

Blood sugar
S. electrolytes

- Hb – 12.7 gm/dl, WBC – 5,200/cmm,
poly – 62%, lympho – 38%,
ESR – 30 mm in 1st hr,
platelets – 1,80,000/cmm.
- 5.1 mmol/L.
- Sodium 142 mmol/L.
Chloride 102 mmol/L.
Potassium 4 mmol/L.
Bicarbonate 23 mmol/L.

Questions
a. What is the likely diagnosis?
b. Suggest 2 investigations.


Case History and Data Interpretation

15

Case No. 018
A lady of 32 years is referred from obstetric department for an urgent
medical opinion. Two days after delivery, the patient developed cough
with profuse frothy sputum, respiratory distress with difficulty on lying

flat, compression in the chest and sweating. She was otherwise well
before delivery.
On examination, the patient looks exhausted, sweaty and dyspneic.
Cyanosis – mild and central.
Anemia – moderate, edema – present and pitting.
BP – 95/55 mm Hg, pulse – 120/min, irregular. respiratory rate –
26/min.
JVP – raised, pulsatile. Liver – enlarged, 3 cm and tender.
Heart – apex shifted to the left, pansystolic murmur in mitral area.
Bilateral basal crepitations – present.
Investigations
• Full blood count

•

Chest X-ray

•
•
•
•
•

RBS
Urea
Creatinine
USG of abdomen
ECG

- Hb – 8.7 gm/dl, WBC – 13,640/cmm,

poly – 80%, lympho – 20%,
platelets – 2,88,000/cmm,
ESR – 78 mm in 1st hr.
- Cardiomegaly, upper lobe
diversion and small bilateral
pleural effusion.
- 7.1 mmol/L.
- 35 mg/dl.
- 1.6 mg/dl.
- Hepatomegaly and bulky uterus.
- Low voltage and atrial fibrillation.

Questions
a. What is the likely diagnosis?
b. What 2 investigations would you suggest?

Case No. 019
A 52-year-old woman presented with frequency of micturition, extreme
weakness, loss of appetite, constipation, abdominal pain and weight
loss for seven months.
On examination, anemia – mild, tongue – dry, BP – 140/100 mm Hg,
pulse – 86/min. Tenderness in epigastric region, no organomegaly.


16

Case History and Data Interpretation in Medical Practice

Investigations
• Full blood count

•
•
•
•
•
•
•

Plain X-ray KUB
USG of abdomen
Urine
RBS
Urea
Creatinine
S. electrolytes

- Hb – 10.6 gm/dl, WBC – 8,900/cmm
poly – 55%, lympho – 43%,
mono – 2%, ESR – 90 mm in 1st hr,
- Nephrocalcinosis.
- Calcification in both kidneys.
- Protein (+), few pus cells.
- 6.9 mmol/L.
- 8.2 mmol/L.
- 1.4 mg/dl.
- Sodium 139 mmol/L.
Chloride 110 mmol/L.
Potassium 3.6 mmol/L.
Bicarbonate 22 mmol/L.

Questions
a. What is the likely diagnosis?
b. Suggest 5 investigations to confirm your diagnosis.
c. What single treatment should be given immediately?

Case No. 020
A 23-year-old lady is admitted in the psychiatry department with the
complaints of violent behavior, refusal of food intake, excitability, no
speech or no response to any command and insomnia for the last one
month. Her mother told that she was suffering from occasional low
grade fever, arthralgia, pain in both eyes with redness, frequency of
micturition and weight loss for the last ten months.
On examination, face – puffy, anemia – severe, edema – pitting and
mild. BP – 125/75 mm Hg, pulse – 90/min, spleen – enlarged, 2 cm.
Higher psychic functions – no response and uncooperative.
Reflexes – all exaggerated. Plantar – equivocal, cranial nerves –
apparently normal. Fundoscopy – soft exudate in both eyes.
Investigations
• Full blood count

- Hb – 6.1 gm/dl, WBC – 5,600/cmm,
poly – 61%, lympho – 36%,
eosinophil – 3%,
platelets – 87,000/cmm,
ESR – 130 mm in 1st hr.


Case History and Data Interpretation
•
•

•
•
•

PBF
Reticulocyte
Coomb’s test
Urine
Chest X-ray

-

•
•
•
•
•

RBS
Urea
Creatinine
USG of abdomen
CT scan of brain

-

17

Macrocytosis and polychromasia.
5.2% (normal 0.2 to 2%).

Positive.
Protein (++).
Cardiomegaly with small bilateral
pleural effusion.
7.1 mmol/L.
35 mg/dl.
2.6 mg/dl (normal 0.57 to 1.36).
Splenomegaly with mild ascites.
Widening of the cortical sulci with
small infarction in the
parietal region on left side.

Questions
a. What is the likely diagnosis?
b. Suggest 4 investigations.

Case No. 021
A 20-year-old student is complaining of sore throat, pain in the right
ear with discharge, which developed three days after a trauma in the
head during playing. He was always in good health.
No fracture in skull, no obvious head injury. After 3 days, he
developed high fever, headache, transient loss of consciousness lasted
for few seconds, blurring of vision, followed by convulsion.
On examination, neck rigidity – present.
Weakness on the left side of body.
All reflexes on left side – exaggerated.
Plantar – extensor on both sides.
Homonymous hemianopia – left side.
Ataxia – left side.
2 point discrimination – present.

Fundoscopy – normal.
Lumbar puncture and CSF study shows:
• Pressure
- 30 cm of H2O (normal 50 to 180).
• Cells
- 4/cmm, all lymphocytes (normal 0 to 4).
• Protein
- 15 mg/dl (normal 15 to 40).
• Glucose
- 41 mg/dl (normal 28 to 45).


18

Case History and Data Interpretation in Medical Practice

Questions
a. What is your diagnosis?
b. Suggest 3 investigations which will help your diagnosis.

Case No. 022
A 27-year-old lady is referred from psychiatry department for an urgent
medical opinion. This lady was suffering from psychiatric disorder for
3 years, feeling better with antipsychotic drugs. For the last 3 weeks,
she has been suffering from high grade continuous fever, associated
with chill and rigor, subsides with high dose paracetamol. She is
also complaining of anorexia, loss of weight, difficulty in deglutition,
stiffness of muscles, palpitation and syncopal attack. Five years back,
she was suffering from pulmonary tuberculosis, completed full course
of anti-TB drugs.

On examination, looks emaciated, mildly anemic, BP – 90/65 mm Hg,
pulse – 120/min, Temp – 105.2ºF. Heart and lungs – Normal.
Neck rigidity – present.
Higher psychic functions – the patient is uncooperative. No or little
response to command.
Muscle tone – increased in both upper and lower limbs.
Reflex – difficult to elicit. Plantar – equivocal on both sides.
Investigations
• Full blood count

•
•
•
•
•
•
•

Urine
Blood and urine
culture
Chest X-ray
RBS
Urea
Creatinine
S. electrolytes

•

MT

- Hb – 11.1 gm/dl, WBC – 15,600/cmm,
poly – 87%, lympho – 13%,
platelets – 1,87,000/cmm,
ESR – 60 mm in 1st hr.
- Pus cells – few and protein (++).
- Negative.
-

Normal.
7.1 mmol/L.
35 mg/dl.
1.2 mg/dl.
Sodium 138 mmol/L.
Potassium 4.2 mmol/L.
Bicarbonate 22.8 mmol/L.
Chloride 105 mmol/L.
- 12 mm.


Case History and Data Interpretation
•
•

USG of abdomen
CT scan of brain

19

- Normal.

- Normal.

Questions
a. What is the likely diagnosis?
b. Suggest 3 investigations.
c. Suggest 1 investigation helpful to confirm your diagnosis.

Case No. 023
A lady of 70 years presented with the complaints of breathlessness
even on mild exertion, occasional dry cough and marked loss of weight
for two years.
Lung function test shows:
• Vital capacity
- 2.3 liters/sec (predicted 3.28 to 4.43 L).
• FEV1
- 0.7 liters/sec (predicted 2.44 to 3.33 L).
• Residual volume
- 5.11 liters/sec (predicted 1.35 to 1.83 L).
Questions
a. What does this lung function test indicate?
b. What is the likely diagnosis?
c. Suggest 2 further investigations.

Case No. 024
A school going girl of 14 years is admitted in a surgical ward with
severe acute abdominal pain, repeated vomiting and bloody diarrhea.
On the 3rd day, she develops pain in both knee and ankle joints,
multiple urticarial rash, few purpura and scanty micturition.
On examination, the patient looks pale, BP- 150/100 mm Hg, pulse100/min, anemia—mild, jaundice—absent.
Abdomen—tenderness in the epigastrium and around umbilicus.

Examination of other systems reveal no abnormality.
Investigations
• Full blood count

•

MCV

- Hb – 9.8 gm/dl, WBC – 6,200/cmm,
poly – 74%, lympho – 26%,
ESR – 57 mm in 1st hr,
platelets – 1,95,000/cmm.
- 71 fl.


20
•
•
•

•
•
•

Case History and Data Interpretation in Medical Practice

Plain X-ray abdomen - multiple fluid level and
gas shadow.
Blood sugar
- 5.1 mmol/L.

S. electrolytes
- Sodium 136 mmol/L.
Chloride 98 mmol/L.
Potassium 4.1 mmol/L.
Bicarbonate 21 mmol/L.
Urine
- Protein (+), RBC cast (++).
USG of abdomen
- Full of gas shadow.
Chest X-ray
- Normal.

Questions
a. What is your diagnosis?
b. Suggest 2 investigations which will help your diagnosis.
c. Suggest 1 investigation which will help in prognosis.

Case No. 025
A young student presented with weakness, anorexia, nausea and high
colored urine for two days. He was suffering from fever, cough, pain
in the throat and headache 10 days back.
There is history of previous similar attack.
On examination, anemia – mild, jaundice – mild, liver – just
palpable, non-tender.
Investigations
• Full blood count
•
•
•
•

•
•

- Hb – 10.2 gm/dl, ESR – 32 mm in
1st hr, WBC – 9,900/cmm, poly – 61%,
lympho – 35%, monocyte – 4%.
Reticulocyte count
- 0.7% (normal 0.2 to 2).
Total bilirubin
- 52 μmol/L (normal <17).
ALT (SGPT)
- 15 IU/L (normal <20).
AST (SGOT)
- 21 IU/L (normal <25).
Alkaline Phosphatase - 42 IU/L (normal 20 to 100).
USG of abdomen
- Slight hepatomegaly.

Questions
a. What is the diagnosis?
b. Suggest 2 investigations.
c. What treatment would you give to the patient?


Case History and Data Interpretation

21

Case No. 026
A middle aged man was hospitalized with the complaints of anorexia,

nausea, vomiting and frank blood stained urine. On the third day of
illness, there is complete anuria. One day before admission, there was
history of fall with multiple injuries in the body, but no fracture.
On examination, face-puffy. BP – 160/110 mm Hg, pulse – 97/min,
anemia – mild, edema – pitting. Multiple bruise and ecchymoses – in
trunk and buttock.
Investigations
• Full blood count

•
•
•
•

Urea
Creatinine
Blood sugar
S. electrolytes

•

Urine

- Hb – 9 gm/dl, WBC – 13,200/cmm,
poly – 67%, lympho – 33%,
ESR – 70 mm in 1st hr,
platelets – 1,99,000/cmm.
- 14 mmol/L (normal 2.5 to 6.6).
- 9 mg/dl (normal 0.68 to 1.36).
- 4.8 mmol/L.

- Sodium 132 mmol/L.
Chloride 92 mmol/L.
Potassium 6.1 mmol/L.
Bicarbonate 14 mmol/L.
- Mild proteinuria, no RBC or
pus cell.

Questions
a. What is your diagnosis?
b. Suggest 2 investigations to confirm your diagnosis.
c. What immediate treatment should be given?

Case No. 027
A 68-year-old woman has been suffering from low grade, continuous
fever, arthralgia, loss of appetite, sweating mostly at night and weight
loss for 5 months.
For the last 2 months, she is also complaining of severe pain in both
knee joints and frequent headache, mostly on temporal and occipital
region with occasional difficulty in vision.
Investigations
• Full blood count

- Hb – 9.8 gm/dl, WBC – 10,500/cmm,
poly – 63%, lympho – 25%,


22

Case History and Data Interpretation in Medical Practice

•

Urine

-

•
•
•
•
•
•
•

Chest X-ray
USG of abdomen
MT
CRP
RA test
ANA
Blood and urine
culture
CT scan of brain

-

•

eosinophil – 8%, monocyte – 4%,
platelets – 3,98,000/cmm,

ESR – 135 mm in 1st hr.
Proteinuria (++), few RBC and
pus cells.
Normal.
Normal.
07 mm.
39 mg/dl (normal <10).
Negative.
Negative.
No growth.

- Mild cerebral atrophy.

Questions
a. What is the likely diagnosis?
b. Suggest 1 investigation to confirm the diagnosis.
c. What drug should be started immediately and why?

Case No. 028
A man of 40 years presented with the complaints of weight loss,
anorexia, occasional loose stool and abdominal distension for six
months. There is history of itchy vesicular rash on his buttock and
around both the knees five years ago.
On examination, anemia – moderate, jaundice – absent. Tongue –
smooth and shiny. No other abnormality.
Investigations
• Full blood count
•
•
•

•

MCHC
MCV
USG of abdomen
PBF

•

Stool

- Hb – 8.7 gm/dl, WBC – 10,700/cmm,
poly – 70%, lympho – 30%,
ESR – 50 mm in 1st hr.
- 31.3 gm/dl.
- 98 fl.
- Slight hepatomegaly.
- Macrocytosis, microcytosis,
anisopoikilocytosis, few pencil cells
and hypersegmented neutrophil.
- Vegetable cells plenty, no growth
on culture.


Case History and Data Interpretation

23

Questions
a. What is the cause of hematological findings?

b. Suggest the likely diagnosis.
c. What 2 investigations would confirm the diagnosis?
d. What was the cause of rash?
e. What 2 additional findings may be seen in blood film?
f. What advice would you give to the patient?

Case No. 029
A 19-year-old girl is admitted in the hospital with severe abdominal
pain, burning micturition, vomiting, bloody diarrhea, bodyache,
multiple skin rashes and high fever for 5 days. Her menstruation is
irregular, but this time, it is persistent for 10 days with heavy bleeding.
In her past medical history, tonsillectomy was done at the age of
five and also appendicectomy at the age of seventeen years.
On examination, the patient looks very ill, BP – 70/50 mm Hg,
pulse – 120/min, lower abdomen – very tender. Temperature – 39.7ºC.
There are multiple maculopapular, reddish skin rashes all over the
body.
Investigations
• Full blood count
•
•
•
•
•

Urine
Chest X-ray
Urea
Creatinine
S. electrolytes

•

Prothrombin time

- Hb – 11.3 gm/dl, WBC – 19,570/cmm,
poly – 86%, lympho – 14%,
platelets – 1,00,000/cmm.
- Plenty of pus cells and RBC are plenty.
- Normal.
- 65 mg/dl.
- 1.2 mg/dl.
- Sodium 125 mmol/L.
Potassium 3.1 mmol/L.
Bicarbonate 28.8 mmol/L.
Chloride 95 mmol/L.
- 17.3 sec (control 11).

Questions
a. What is your diagnosis?
b. Suggest 2 investigations.
c. What further history would you take?
d. Mention 1 serious complication.


24

Case History and Data Interpretation in Medical Practice

Case No. 030

A lady of 27 years is admitted in emergency department with
unconsciousness in the morning. She had marital dysharmony for few
years. Her husband told that she used to take sleeping tablet, but he
does not know the name of the tablet.
On examination, patient is semiconscious, less response to painful
stimulus. BP – 80/60 mm Hg, pulse – 140/min, Neck rigidity – present.
Muscle tone – increased. All reflexes – exaggerated. Plantar –
extensor on both sides. Pupil – dilated.
Few spontaneous myoclonic twitching – present.
Investigations
• Full blood count

•
•

RBS
S. electrolytes

•
•
•

Urea
Creatinine
Chest X-ray

- Hb – 12.8 gm/dl, WBC – 14,500/cmm,
poly – 74%, lympho – 25%,
eosinophil – 1%,
platelets – 3,90,000/cmm,

ESR – 15 mm in 1st hr.
- 9 mmol/L.
- Sodium 135 mmol/L.
Potassium 4.3 mmol/L.
Bicarbonate 17.8 mmol/L.
Chloride 95 mmol/L.
- 46 mg/dl.
- 1.3 mg/dl.
- Normal.

Questions
a. What is your diagnosis?
b. Suggest 2 further investigations.
c. What 2 therapeutic measures would you start?

Case No. 031
A lady of 61 years, hypertensive and diabetic, is feeling unwell,
weakness and sleeplessness for ten days. On the day of admission,
she was found to be drowsy and hyperventilating. She was on enalapril
for hypertension and metformin for diabetes mellitus.
There was a past history of myocardial infarction three years back
with good recovery.


Case History and Data Interpretation

25

On examination, the patient is drowsy, unable to communicate, also
hyperventilating. BP – 95/65 mm Hg, pulse – 82/min, low volume.

No neck rigidity, No focal neurological signs. No other abnormality.
Investigations
• Full blood count
•
•
•
•

RBS
Serum urea
Serum creatinine
S. electrolytes

•

Urine

- Hb – 13.2 mg/dl, WBC – 11,000/cmm,
poly – 76%, lympho – 24%,
ESR – 50 mm in 1st hr.
- 11.3 mmol/L.
- 9.1 mmol/L.
- 1.2 mg/dl.
- Sodium 143 mmol/L.
Chloride 97 mmol/L.
Potassium 5.6 mmol/L.
Bicarbonate 7.9 mmol/L.
- Glucose (++).

Questions

a. What is the likely diagnosis?
b. Suggest 3 investigations for your diagnosis.
c. What 2 therapeutic measures should be started?
d. Mention 4 differential diagnoses of such blood picture.

Case No. 032
A 48-year-old man has been suffering from inflammatory bowel disease
for 10 years. He is on olsalazine and his disease is well controlled.
For the last few weeks, he is suffering from weakness, loss of appetite
and weight loss.
On examination, anemia – moderate, clubbing – present.
Leuconychia – present. BP – 100/60 mm Hg, pulse – 74/min. Liver –
enlarged, 3 cm.
Investigations
• Full blood count

•
•

MCV
S. bilirubin

- Hb – 8.3 gm/dl, WBC – 6,500/cmm,
poly – 66%, lympho – 24%,
mono – 3%, eosinophil – 7%,
platelets – 2,90,000/cmm,
ESR – 20 mm in 1st hr.
- 69 fl (normal 76 to 96).
- 20 μmol/L (normal 2 to 17).