Benha University Faculty of Medicine

Master degree of Dermatology Int. med. Course exam. 19-6-2012

Time allowed 3 hour Number of papers: 2

Answer

(Total marks 50)

1– Pericardial effusion in systemic disorders ( 10 causes ): ( 5marks)

i- collagen diseases ( RA , SLE ,SS )

ii- FMF

iii- Infections as lyme disease, TB

iv- sarcoidosis

v- hypothyroidism

vi- IBD

vii- wagner's granulomatosus

viii- uremia ( R.F )

ix- malignancies ( leukemia , lymphoma , lung cancer )

x- Amyloidosis

2 - proteinuria ( def. , 5 causes, 5 sequale ): ( 5marks)

Proteinuria is defined as urinary protein excretion of more tha 150 mg/day 5 types:

i- glomerular proteinuria

due to increased glomerular permeability

as - minimal change disease , MPGN , Ig A nephropathy , DM , amyloidosis,

ii- tubular proteinuria

due to decreased proximal tubular reabsorption of normally filtered ptns , usually less than 2 gm/day

as hypertensive nephrosclerosis , acute tubular necrosis , tubulo-interstitial diseases ( interstitial nephritis, urate nephropathy, NSAIDS,sickle cell, fanconi ) iii- overflow proteinuria

due to increased production of low molecular weight proteins

as Bence-Jones proteinuria in MM, hemoglobinuria in intravascular hemolysis , myoglobinuria in rhabdomyolysis iv- orthostatic (postural) proteinuria as in v- functional as in fever , CHF, stress, anaemia, exercise vi- false proteinuria , due to loss of protein from lining of UT as infections , hematuria

5 sequale i- increased incidence of infections ii- anaemia iii- atherosclerosis d.t hyperlipidemia iv- hypercoagulable states d.t loss of antithrombin iii, hypovolemia and increased coagulating factors v- attacks of abdominal pain ( nephritic crisis ) vi- PT dysfunction vii- renal failure ( acute or chronic )

3 – 5 Diabetic emergencies : ( 5marks)

i- hypoglycemic coma affects Type 1 & 2 Diabetic

Secondary to Insulin or Oral Hypoglycemic Medication

Serum Glucose Levels Fall Below Normal Levels

Chch by neuroglycopenic and neurogenic manifestations

Ttt by glucose supplementation , glucagon ii- DKA ( Diabetic ketoacidosis )

common in type I DM ( IDDM )

In an attempt to save the Heart and Brain, the body produces Ketone Bodies from fatty acids( Acetoacetate, Beta-hydroxybutyrate, And Acetone)

Excessive Ketones lead to Acidosis

Chch by nauses,vomiting,abdominal pain,polyuria,kaussmul breathing , acetone odour of breath and hypovolemia

Ttt by fluids , insulin , correction of and acidosis iii-hyperglycemic hyperosmolar non-ketotic coma ( HHNK )

Effects Type 2 Diabetics ,rare in type I

Prominent later in life

Elevated Blood Glucose lead to increases serum osmolarity

This results in Diuresis and Fluid Shift.

Increased Urination causes body wide depletion of Water and Electrolytes

No acidosis

Ttt by fluids and insulin iv- lactic acidosis

ppt. by tissue hypoxia , biguanides( metformin ) , alcoholism

there is anerobic glycolysis with production of leading to sever acidosis this leads to kussmaul's breathing , disturbed consciousness , coma

ttt by I.V fluids , correction of precipitating agents , , even dialysis v- Cerebro-Vascular Stroke

Death or injury of brain tissue that is deprived of oxygen

Caused by a blockage (ischemic) or bleeding (hemorrhagic) of a blood vessel in the brain

Chch by Intoxicated appearance, slurred speech, unconsciousness

Severe headache, vision changes, One-sided weakness on body, Confusion Loss of bladder/bowel control ,Unequal pupils , High blood pressure

4 - Diagnostic tests to assess patient who bleeds ( 5 tests ): ( 5marks)

i- count

low in thrombocytopenia

ii- bleeding time , PFA-100

increased BT or increased PFA-100in dysfunction

normal BT or normal PFA-100 in vascular disorders, dysfibrinoginemia , factor VIII deficiency

iii- PT( )

decrease VII, decresed V in

decreased VII, normal V in vit.K def. , , F VII def.

iv- PTT( Partial thromboplastin time )

corrects with mixing study in FVIII,IX,XI def.( hemophilia ABC)

not correct with mixing study in circulating ( anticoagulant , )

v- thrombine time : increased in dysfibrinoginemia

5 – hepatic involvement in dermatological disorders ( 5 ): ( 5marks)

6- polyneuropathy with nutritional disorders ( 5 causes ) : ( 5marks)

i- thiamine deficiency (dry beri beri )

chch by peripheral sensory neuropathy

ttt by thiamine 100 mg/day and vit. B complex ,diet rich in vitamins

ii- pellagra ( niacin ) deficiency

chch by sensory PN , dermatitis , diarrhea , dementia ttt by Nicotinic acid, 50 mg PO tid or25 mg IV tid; nicotinamide

50-100 mg IM or PO tid

iii- Vit. B12 deficiency ( SCD )

there is combined degeneration of

PN leading to sensory PN

Pyramidal tract leading to paraparesis

Post.column leading to sensory ataxia

Ttt by IM B12, 1000 μg daily for 1 week,

then weekly for 1 month, then monthly or oral B12, 1000 μg daily,

iv- pyridoxine deficiency ( vit B6 )

chch by Neuropathy, sensory ataxia, depression ,Infantile pyridoxine deficient epilepsy

ttt by 50-100 mg PO daily for neuropathy (preventive use if taking B6 antagonist)

v- copper deficiency

chch by Myelopathy, neuropathy

ttt by elemental cu

7- 5 risk factors for pulmonary embolism: ( 5marks)

Aquired

 Advanced age  Obesity  Previous thromboembolism  Prolonged immobility  Hypercoagulable state  Congestive heart failure  Primary pulmonary hypertension  Chronic obstructive pulmonary disease (COPD)  Malignancy  Stroke  Inflammatory bowel disease  Varicose veins  Pregnancy and postpartum period  Estrogen therapy such as oral contraceptives or hormone replacement therapy  Indwelling vascular devices  Surgery/postoperative  Trauma (especially spinal injuries and long bone fractures)  Severe burns

Inherited

 Protein C, protein S, and antithrombin III deficiencies  Activated protein C resistance ( Leiden)  Hyperhomocysteinemia  Prothrombin gene mutation  Antiphospholipid syndrome 

8 – 5 Systemic causes of GIT Bleeding : ( 5marks)

i- hemorrhagic blood diseases ( thrombocytopenia , coagulopathy )

ii- vasculitis ( e.g PAN , Henoch Schonlein purpura )

iii- uremia

iv- anticoagulant therapy

v- hereditary hemorrhagic telangiectasia

vi- DKA MCQ (10 marks):

All questions answered by (false) or (true):

1-The pain of myocardial ischemia: a) Is typically induced by exercise and relieved by rest. b) Radiates to the neck and jaw but not teeth. c) Rarely lasts longer than 10 seconds after resting. d) Is easily distinguished from esophageal pain.

2-In Infective endocarditis a) Streptococci and staphylococci account for over 80% of cases b) left heart valves are more frequently involved than right heart valves c) normal cardiac valves are not affected d) glomerulonephritis usually occurs due to immune complex disease

3-Finger clubbing is atypical finding in: a) Chronic bronchitis b) Bronchiectasis c) Primary biliary cirrhosis d) Crypto genie fibrosing alveolitis

4 The following statements about thyrotoxicosis are true a) most cases are due to Graves' disease b) muttinodular goitre is more common than uninodular goitre c) amiodarone treatment is occasionally responsible d) the thyroid gland is diffusely hyperactive in Graves' disease

5-Causes of dysphagia include a) Cancer b) Cervical spondylosis c) Achalasia d) Post-corrosive

6-The following may be a cause of constipation a) Ignoring urge b) Antispasmodics c) Irritable bowel syndrome d) Thyrotoxicosis

7- Pernicious Anemia is characterized by: a. Macrocytic anemia b. Pyramidal lesions c. Splenomegaly d. Deep sensory loss

8- Rheumatoid arthritis may be associated with e. Subcutaneous nodules f. Radial deviation of the hands g. o) Swan.neck deformity of the hands h. Thickening of the u1nar nerve 9-Secondary diabetes is associated with: a) Thiazide diuretic therapy b) Haemochromatosis c) Primary hyperaldosteronism d) Pancreatic carcimona

10-Microscopic heamaturia would be an expected finding in: a) Urinary tract infection. b) Renal papillary necrosis. c) Membranous glomerulonephritis. d) Infective endocarditis.