TUTORIAL 02/04/2015 ECG/X-RAY/DATA INTERPRETATION

40 year old man presented with cough and shortness of breath for six months. Six weeks ago he noticed painful lumps on the skin of his legs which had resolved in two weeks Investigation: FBC: normal Sodium 145 mmol/l Potassium 2.8 mmol/l Chloride 100 mmol/l Urea 2.4 mmol/l Serum creatinine 83 µmol/l Calcium 3.4 mmol/l 1.What is the abnormality in CXR? 2.What is the most likely diagnosis?

Sarcoidosis Infection – Tuberculosis – Fungal infection – Mycoplasma – Intestinal Lipodystrophy (Whipple's disease) Malignancy – Lymphoma – Carcinoma – Mediastinal tumors In-organic dust disease – Silicosis – Berylliosis Extrinsic allergic alveolitis – Such as bird fancier's lung Less common causes also exist: – Churg-Strauss syndrome – Human immunodeficiency virus – Extrinsic allergic alveolitis – Adult-onset Still's disease Bilateral hilar lymphadenopathy: Causes

28 year old lady presented with sharp chest pain which radiated to trapezius ridge and was worse in supine position lasted for hours 1.What are conspicuous changes in ECG? 2.What is the likely diagnosis?

Idiopathic causes Infectious conditions: – Viral – Bacterial – TB Inflammatory disorders: – RA – SLE – Scleroderma – Rheumatic fever Metabolic disorders: – Renal failure – Hypothyroidism – Hypercholesterolemia Cardiovascular disorders: – Acute MI – Dressler syndrome – Aortic dissection Miscellaneous causes: – Iatrogenic, – Neoplasms, – Drugs, – Irradiation, – Cardiovascular procedures – Trauma Pericarditis: Causes:

Chest radiographs revealing markedly enlarged cardiac silhouette and normal-appearing lung parenchyma in prepericardiocentesis (A) and postpericardiocentesis (B). Acute pericarditis

H&E stain, medium power magnification showing a rheumatoid nodule in rheumatoid pericarditis, composed of histiocytes and scattered multinucleated giant cells (lower right) surrounding necroinflammatory debris (upper left) RHEUMATOIDARTHRITSRHEUMATOIDARTHRITS

Pap stain, high power magnification of adenocarcinoma metastatic to the pericardium on pericardiocentesis with the red arrow showing a normal mesothelial cell and the black arrowhead showing adenocarcinoma ADENOCARCINOMAADENOCARCINOMA

Investigations: FBC: normal Sodium 145 mmol/l Potassium 2.8 mmol/l Bicarbonate 31 mmol/l Chloride 100 mmol/l Urea 2.4 mmol/l Serum creatinine 83 µmol/l Calcium 2.4 mmol/l Magnesium 0.8mmol/l Chest X-ray: no cardiomegaly ECG: Prolonged Q-T interval and U waves What are the possible causes of patient’s hypokalemia? What is the evidence for alkalosis? Suggest two further non- invasive confirmatory investigations? 36 year old lady presented with muscle weakness, cramps, numbness and tingling of hands and feet. She was diagnosed hypertension four years previously and has been on atenolol 100 mg OD. O/E Pulse 60/minute; BP 155/100 mm Hg. Mild weakness proximally. Rest of examination was normal.

1.What does chest X-ray show? 2.What is the likely diagnosis? A man with difficulty in swallowing A 63 year old man presented with two month history of dysphagia. Barium swallow suggests a smooth stricture at the gastro-esophageal junction and the following report was obtained after gastro-esophageal manometery. “The resting gastro-esophageal sphincter pressure is increased and sphincter fails to relax with swallowing. After swallowing there are no peristaltic contractions occurring simultaneously.”

Barium swallow demonstrating the bird-beak appearance of the lower esophagus, dilatation of the esophagus, and stasis of barium in the esophagus. Esophageal manometry (the criterion standard): Incomplete LES relaxation in response to swallowing, high resting LES pressure, absent esophageal peristalsis Prolonged esophageal pH monitoring to rule out gastroesophageal reflux disease and determine if abnormal reflux is being caused by treatment Esophagogastroduodenoscopy to rule out cancer of the GEJ or fundus Concomitant endoscopic ultrasonography if a tumor is suspected

A 40 year old man presented with fatigue, fever and painful goitre. The results of investigations were as follows: Hb 14.3 g/dl WBC 11.2 x 10 9/l ESR 100 mm in the first hour T432.4pmol/l (NR 9.4 – 24.5) TSH ˂ 0.1mU/l (NR 0.5 – 5.5 ) Radio-iodine 131 thyroid scan: uptake at 4 hours ˂ 5% (normal range 6 -18%) 1.What are the lab result abnormalities? 2.What is the most likely diagnosis? 3.What treatment is required? A man with painful goitre

A woman with renal calculi 30 year old woman presenting with renal calculi had the following results: Urea 6.0 mmol/ Sodium 138 mmol/l Potassium2.9 mmol/l Bicarbonate 13 mmol/l Albumin 41 g/l Calcium 2.0 mmol/l Phosphate0.8 mmol/l 1.What X-ray show? 2.What are lab result abnormalities? 3.Will parathyroid hormone concentration prove high or low ?