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Benha University Faculty of Medicine Answer 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 pregnancy 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 electrolytes 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 lactic acid leading to sever acidosis this leads to kussmaul's breathing , disturbed consciousness , coma ttt by I.V fluids , correction of precipitating agents , bicarbonate , 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- platelets count low in thrombocytopenia ii- bleeding time , PFA-100 increased BT or increased PFA-100in platelet dysfunction normal BT or normal PFA-100 in vascular disorders, dysfibrinoginemia , factor VIII deficiency iii- PT( Prothrombin time ) decrease VII, decresed V in liver disease decreased VII, normal V in vit.K def. , warfarin, 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 ( lupus anticoagulant , heparin ) 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 (factor V Leiden) Hyperhomocysteinemia Prothrombin gene mutation Antiphospholipid antibody syndrome Lupus anticoagulant 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. .
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