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hello, i am an american student entering med school in the states in july. i am currently studying abroad and am having a little trouble with one of my finals, which consists of answering case histories. i have a few samples here and i was wondering if a current med student could please help me out.
the system here is different; as medicine is an undergraduate course, i have not previously learned some of the topics so my knowledge is jumbled. the questions ive attempted are in italics.
if anyone could help me i would really appreciate it. thank you.
Case History 1
A 45-year old lady consulted her family doctor because she had noticed a recent enlargement in the size of her left breast. She has no other medical problems but has a positive family history of breast cancer, her mother having died of the disease at the age of 50. She has two daughters, aged 22 and 25 years, who are both apparently well.
On examination, the family doctor noticed a 2cm mass in her left breast. The mass was hard, poorly defined and caused dimpling of the skin. It was also fixed to the underlying tissues. The nipple and areola on that side had an eczematous appearance. The axillary lymph nodes appeared of normal size and consistency and the right breast was not enlarged and did not have any nodules.
The family doctor suspected that it was malignant cancer of breast and referred the patient to hospital for further tests.
Q1.Why did the family doctor consider that the nodule in the left breast was malignant?
Mass was fixed to underlying tissues
Q2. What histological features of the specimen would confirm that the cancer is malignant?
Changes in nucleus/cytoplasm ratio
Dark, dense, enlarged, misshaped nucleus
Q3. Name four locations to which a malignant breast cancer can spread to?
Liver, lymph nodes, bones, brain, lungs
Q4. Which biochemical investigations will help monitor the effect of any metastatic spread of the cancer?
Liver LFTs (AST, ALP, albumin, bilirubin)
Bones bone fuction tests, bone profile (ALP, phosphate, albumin, calcium)
Q5. What results would you expect if metastasis has occurred?
Progressive changes in LFTs
Focal liver damage (isolated rise in ALP)
Q6. What other causes could produce these abnormal results?
Viral hepatitis (elevated AST and ALP)
Cirrhosis (elevated GGT)
Osteoporosis, osteomalacia (vitamin D deficiency)
Hypoparathyroidism
Q7. In the light of the patients family history, what genetic tests would you suggest should be carried out?
Q8. What tests would you recommend were carried out on the patients biopsy for selection of appropriate therapy?
The patient was started on a course of tamoxifen in combination with methotrexate and 5-fluorouracil.
Q9. What are the main side effects of chemotherapy in general and of the three drugs above in particular?
Early onset osteoporosis, gum disease, alopecia, endocrine changes, nausea, vomiting, nephrotic effects (GFR, CCr), haematological problems (WBC, RBC, Hb)
Q10 What biochemical and haematological investigations should be carried out to monitor patients on chemotherapy? What results would you expect?
Case History 2
A 58 year old female noticed changes in the contours of her right breast in February 2007. During the following months, the patient stated that she was fatigued to the point where she was unable to walk around in her home or to perform her ADLs (Activities of Daily Living) without resting. She also noticed cracking of her nails and changes in the hair growth over her temples. Over the next year, the patient's general condition worsened with increasing fatigue. She began having night sweats, and she developed pain in her left hip and lower back occasionally severe enough to prevent ambulation. She persisted in her own ways, working with a variety of non-traditional therapies. In July of 2008, she noticed a thickening and hardness in her right breast extending up to the clavicle. She began to experience episodic pain in the breast mass with radiation up to the right side of her neck. At this point, she consulted her GP who immediately referred her to a specialist. She was admitted to hospital for relevant laboratory tests and imaging. Subsequently, she was offered a modified radical mastectomy, however she elected not to have the surgery. She was quite clear within herself about avoiding the potential physical damage that surgery would involve.
PAST MEDICAL HISTORY: No relevant past history.
FAMILY HISTORY: Significant family history of cancer involving maternal grandmother, aunts, cousins and nephews; her mother died of breast cancer. No family history of heart disease, diabetes, or tuberculosis.
SYSTEM REVIEW: Fatigue to the point of exhaustion; weight loss of 5 lbs; cracking/splitting of finger nails; hair loss, abnormal hair growth (short) over temples; pain in right breast; constipation; pain in left hip and lower back. The rest of the system review was negative for all systems inquired.
PHYSICAL EXAMINATION: Height: 5 ft. 4 in. Weight: 110 lbs BP: 100/64 P: 80/min. T: 97.4F Patient was a 58 year old female looking older than her stated age, facies pale and had lost 5 lbs since onset of her present illness. There was a firm, tender mass, 3 x 2 cm., in the upper outer quadrant of the right breast. The mass was fixed to the underlying fascia and caused dimpling of the overlying skin. There was no gross inflammatory response and no discharge from the right nipple which was eczematous and retracted. Left breast was normal. The right axillary lymph nodes were enlarged and firm but not tender. Liver was enlarged and easily palpable. Head & Neck: No palpable nodes or thyroid. Rectal and pelvic exam: Normal.
Q1. What is the differential diagnosis i.e. make a list of conditions which can give rise to the above clinical picture.
TB, lymphoma, breast infection, fibrocystic disease, breast carcinoma
Q2. Which of these diagnoses are (i) least likely and (ii) most probable, and why?
Fibrocystic disease is least likely because the mass is local.
Breast carcinoma is most likely because of the pts pfmx, night pain, mass is fixed and immobile, weight loss, axillary lymph node swelling, low back and hip pain, hepatomegaly
Q3. What investigations would have been done in the hospital to reach a final diagnosis? Explain how each of the listed investigation is helpful in arriving at the correct diagnosis?
ESR will be elevated in malignant chronic disease
C reactive protein elevated in acute disease
HB rule out fatigue from anaemia
WBC differential: neutrophils (acute bacterial), eosinophils (parasitic), lymphocytes (viral), monocytes (chronic bacterial), basophils (allergies)
Cancer markers more important in prognosis than diagnosis
LFTs
US fluid vs solid mass
Mammogram size, shape, calcification of tumor
XR skeletal secondaries, fractures, TB
TB sputum, stool sample
MRI/CT, radioisotope scan
Biopsy check for basement membrane integrity, pleiomorphism, mitotic figures, intravastation. Fine needle aspiration risks damaging blood vessels and spreading the disease.
Q4. Describe the pathological basis of (i) retraction of the nipple (ii) dimpling of skin overlying the breast (iii) Enlarged and firm but pain free axillary lynph nodes (iv) enlarged liver and (v) pain in the left hip and the low back.
Q5. What is the prognosis of this patient?
Q6. If this patient had seen her GP at the onset of her illness or opted to have surgery, would the prognosis be different?
Case History 3
A 43-year-old female presented to her GP with one month of abdominal pain, nausea, vomiting and early satiety. Patient had been working as a missionary in Portugal 8 months prior to presentation; about 1 week after her arrival, she began to have watery diarrhoea (56 episodes/day) for which she states she received "pills."
CT abdomen and pelvis followed by a liver biopsy were performed while the patient was in Portugal. She was given a diagnosis of cancer after a mass was seen on CT and liver biopsy exhibited evidence of malignancy.
The patient relocated to the UK. Upon arrival she described her pain as crampy, radiating to the right flank associated with nausea and bilious vomiting. She reported as well to have had an unintentional weight loss of 50 lbs (23 kg) in the last 8 months with loss of appetite.
Pertinent physical exam findings were a palpable liver 7 cm below the costal margin and diffusely across the entire abdomen.
A liver biopsy revealed proliferation of neoplastic cells resembling hepatocytes, arranged in large trabeculae and nests, giving the impression of a well-differentiated liver carcinoma.
The patient was admitted and based on the extent of the lesions, had bland particle embolization of the left lobe of the liver with improvement in her abdominal pain, and was subsequently able to be discharged tolerating oral feeds.
Q1. Make a list of conditions which can give rise to the above clinical picture. That is, what is the differential diagnosis?
Q2. Which of these diagnoses are least likely and most probable and explain why.
Q3. Which one of the investigations that were done do you consider to be the most helpful in reaching a final diagnosis? Explain how each of the listed investigation is helpful in arriving at the correct diagnosis?
Q4. Outline the pathological basis of (i) HCC (ii) Enlarged liver (iii) Jaundice (iv) Portal Hypertension, and (v) Ascites.
The patient returned to her GP reporting a return of the watery diarrhoea occurring with some frequency. Various investigations were undertaken in line with an exacerbation of the patients known current morbidity. Nothing conclusive was established. A sample of stool was then sent to microbiology. The organism was cultured and a direct Grams stain of the faecal material was undertaken. The Grams stain showed the presence of an abundance of curved Gram negative rods. Following culture an organism was grown and was shown to be catalase positive and oxidise negative. The patient was monitored, and she continued to have episodes of diarrhoea, the patients skin started to become leathery and less elastic and she became more confused. The patient also started to complain of systemic joint pain.
Q5. What do you think is the current diagnosis for this patient?
Q6. Examining the biochemistry and Grams Stain evidence regarding the microbiology what might the identity of the organism be and what are your reasons for suggesting the organism that you have?
Q7. What are the treatment options to tackle the infection by the organism? In addition why has the patients skin become less elastic and leathery and what might be done to alleviate these symptoms?
Q8. What is the prognosis of this patient?
Lab results:
Total Bilirubin 34.0 µmol/L 3.0 25 µmol/L
Direct Bilirubin 25 µmol/L < 1 µmol/L
AST 448 IU/L 5 43 IU/L
ALT 185 IU/L 5 60 IU/L
ALP 185 IU/L 30 115 IU/L
GGT 868 IU/L 5 80 IU/L
Total Protein 76 g/L 60 84 g/L
Albumin 30 g/L 39 50 g/L
CEA (Carcinoembryonic Antigen ) 1 µg/L < 2.5 µg/L
Hepatitis Profile non-reactive
ANA titre 1:40 1:40
Ferritin 103 µg/L male < 40y 30-233
male > 40y 32-284
female pre-menopausal 6-81
female post-menopausal 14-186
(all in µg/L)
Alpha-1-anti-trypsin 1.5 g/L 1.0 3.0 g/L
the system here is different; as medicine is an undergraduate course, i have not previously learned some of the topics so my knowledge is jumbled. the questions ive attempted are in italics.
if anyone could help me i would really appreciate it. thank you.
Case History 1
A 45-year old lady consulted her family doctor because she had noticed a recent enlargement in the size of her left breast. She has no other medical problems but has a positive family history of breast cancer, her mother having died of the disease at the age of 50. She has two daughters, aged 22 and 25 years, who are both apparently well.
On examination, the family doctor noticed a 2cm mass in her left breast. The mass was hard, poorly defined and caused dimpling of the skin. It was also fixed to the underlying tissues. The nipple and areola on that side had an eczematous appearance. The axillary lymph nodes appeared of normal size and consistency and the right breast was not enlarged and did not have any nodules.
The family doctor suspected that it was malignant cancer of breast and referred the patient to hospital for further tests.
Q1.Why did the family doctor consider that the nodule in the left breast was malignant?
Mass was fixed to underlying tissues
Q2. What histological features of the specimen would confirm that the cancer is malignant?
Changes in nucleus/cytoplasm ratio
Dark, dense, enlarged, misshaped nucleus
Q3. Name four locations to which a malignant breast cancer can spread to?
Liver, lymph nodes, bones, brain, lungs
Q4. Which biochemical investigations will help monitor the effect of any metastatic spread of the cancer?
Liver LFTs (AST, ALP, albumin, bilirubin)
Bones bone fuction tests, bone profile (ALP, phosphate, albumin, calcium)
Q5. What results would you expect if metastasis has occurred?
Progressive changes in LFTs
Focal liver damage (isolated rise in ALP)
Q6. What other causes could produce these abnormal results?
Viral hepatitis (elevated AST and ALP)
Cirrhosis (elevated GGT)
Osteoporosis, osteomalacia (vitamin D deficiency)
Hypoparathyroidism
Q7. In the light of the patients family history, what genetic tests would you suggest should be carried out?
Q8. What tests would you recommend were carried out on the patients biopsy for selection of appropriate therapy?
The patient was started on a course of tamoxifen in combination with methotrexate and 5-fluorouracil.
Q9. What are the main side effects of chemotherapy in general and of the three drugs above in particular?
Early onset osteoporosis, gum disease, alopecia, endocrine changes, nausea, vomiting, nephrotic effects (GFR, CCr), haematological problems (WBC, RBC, Hb)
Q10 What biochemical and haematological investigations should be carried out to monitor patients on chemotherapy? What results would you expect?
Case History 2
A 58 year old female noticed changes in the contours of her right breast in February 2007. During the following months, the patient stated that she was fatigued to the point where she was unable to walk around in her home or to perform her ADLs (Activities of Daily Living) without resting. She also noticed cracking of her nails and changes in the hair growth over her temples. Over the next year, the patient's general condition worsened with increasing fatigue. She began having night sweats, and she developed pain in her left hip and lower back occasionally severe enough to prevent ambulation. She persisted in her own ways, working with a variety of non-traditional therapies. In July of 2008, she noticed a thickening and hardness in her right breast extending up to the clavicle. She began to experience episodic pain in the breast mass with radiation up to the right side of her neck. At this point, she consulted her GP who immediately referred her to a specialist. She was admitted to hospital for relevant laboratory tests and imaging. Subsequently, she was offered a modified radical mastectomy, however she elected not to have the surgery. She was quite clear within herself about avoiding the potential physical damage that surgery would involve.
PAST MEDICAL HISTORY: No relevant past history.
FAMILY HISTORY: Significant family history of cancer involving maternal grandmother, aunts, cousins and nephews; her mother died of breast cancer. No family history of heart disease, diabetes, or tuberculosis.
SYSTEM REVIEW: Fatigue to the point of exhaustion; weight loss of 5 lbs; cracking/splitting of finger nails; hair loss, abnormal hair growth (short) over temples; pain in right breast; constipation; pain in left hip and lower back. The rest of the system review was negative for all systems inquired.
PHYSICAL EXAMINATION: Height: 5 ft. 4 in. Weight: 110 lbs BP: 100/64 P: 80/min. T: 97.4F Patient was a 58 year old female looking older than her stated age, facies pale and had lost 5 lbs since onset of her present illness. There was a firm, tender mass, 3 x 2 cm., in the upper outer quadrant of the right breast. The mass was fixed to the underlying fascia and caused dimpling of the overlying skin. There was no gross inflammatory response and no discharge from the right nipple which was eczematous and retracted. Left breast was normal. The right axillary lymph nodes were enlarged and firm but not tender. Liver was enlarged and easily palpable. Head & Neck: No palpable nodes or thyroid. Rectal and pelvic exam: Normal.
Q1. What is the differential diagnosis i.e. make a list of conditions which can give rise to the above clinical picture.
TB, lymphoma, breast infection, fibrocystic disease, breast carcinoma
Q2. Which of these diagnoses are (i) least likely and (ii) most probable, and why?
Fibrocystic disease is least likely because the mass is local.
Breast carcinoma is most likely because of the pts pfmx, night pain, mass is fixed and immobile, weight loss, axillary lymph node swelling, low back and hip pain, hepatomegaly
Q3. What investigations would have been done in the hospital to reach a final diagnosis? Explain how each of the listed investigation is helpful in arriving at the correct diagnosis?
ESR will be elevated in malignant chronic disease
C reactive protein elevated in acute disease
HB rule out fatigue from anaemia
WBC differential: neutrophils (acute bacterial), eosinophils (parasitic), lymphocytes (viral), monocytes (chronic bacterial), basophils (allergies)
Cancer markers more important in prognosis than diagnosis
LFTs
US fluid vs solid mass
Mammogram size, shape, calcification of tumor
XR skeletal secondaries, fractures, TB
TB sputum, stool sample
MRI/CT, radioisotope scan
Biopsy check for basement membrane integrity, pleiomorphism, mitotic figures, intravastation. Fine needle aspiration risks damaging blood vessels and spreading the disease.
Q4. Describe the pathological basis of (i) retraction of the nipple (ii) dimpling of skin overlying the breast (iii) Enlarged and firm but pain free axillary lynph nodes (iv) enlarged liver and (v) pain in the left hip and the low back.
Q5. What is the prognosis of this patient?
Q6. If this patient had seen her GP at the onset of her illness or opted to have surgery, would the prognosis be different?
Case History 3
A 43-year-old female presented to her GP with one month of abdominal pain, nausea, vomiting and early satiety. Patient had been working as a missionary in Portugal 8 months prior to presentation; about 1 week after her arrival, she began to have watery diarrhoea (56 episodes/day) for which she states she received "pills."
CT abdomen and pelvis followed by a liver biopsy were performed while the patient was in Portugal. She was given a diagnosis of cancer after a mass was seen on CT and liver biopsy exhibited evidence of malignancy.
The patient relocated to the UK. Upon arrival she described her pain as crampy, radiating to the right flank associated with nausea and bilious vomiting. She reported as well to have had an unintentional weight loss of 50 lbs (23 kg) in the last 8 months with loss of appetite.
Pertinent physical exam findings were a palpable liver 7 cm below the costal margin and diffusely across the entire abdomen.
A liver biopsy revealed proliferation of neoplastic cells resembling hepatocytes, arranged in large trabeculae and nests, giving the impression of a well-differentiated liver carcinoma.
The patient was admitted and based on the extent of the lesions, had bland particle embolization of the left lobe of the liver with improvement in her abdominal pain, and was subsequently able to be discharged tolerating oral feeds.
Q1. Make a list of conditions which can give rise to the above clinical picture. That is, what is the differential diagnosis?
Q2. Which of these diagnoses are least likely and most probable and explain why.
Q3. Which one of the investigations that were done do you consider to be the most helpful in reaching a final diagnosis? Explain how each of the listed investigation is helpful in arriving at the correct diagnosis?
Q4. Outline the pathological basis of (i) HCC (ii) Enlarged liver (iii) Jaundice (iv) Portal Hypertension, and (v) Ascites.
The patient returned to her GP reporting a return of the watery diarrhoea occurring with some frequency. Various investigations were undertaken in line with an exacerbation of the patients known current morbidity. Nothing conclusive was established. A sample of stool was then sent to microbiology. The organism was cultured and a direct Grams stain of the faecal material was undertaken. The Grams stain showed the presence of an abundance of curved Gram negative rods. Following culture an organism was grown and was shown to be catalase positive and oxidise negative. The patient was monitored, and she continued to have episodes of diarrhoea, the patients skin started to become leathery and less elastic and she became more confused. The patient also started to complain of systemic joint pain.
Q5. What do you think is the current diagnosis for this patient?
Q6. Examining the biochemistry and Grams Stain evidence regarding the microbiology what might the identity of the organism be and what are your reasons for suggesting the organism that you have?
Q7. What are the treatment options to tackle the infection by the organism? In addition why has the patients skin become less elastic and leathery and what might be done to alleviate these symptoms?
Q8. What is the prognosis of this patient?
Lab results:
Total Bilirubin 34.0 µmol/L 3.0 25 µmol/L
Direct Bilirubin 25 µmol/L < 1 µmol/L
AST 448 IU/L 5 43 IU/L
ALT 185 IU/L 5 60 IU/L
ALP 185 IU/L 30 115 IU/L
GGT 868 IU/L 5 80 IU/L
Total Protein 76 g/L 60 84 g/L
Albumin 30 g/L 39 50 g/L
CEA (Carcinoembryonic Antigen ) 1 µg/L < 2.5 µg/L
Hepatitis Profile non-reactive
ANA titre 1:40 1:40
Ferritin 103 µg/L male < 40y 30-233
male > 40y 32-284
female pre-menopausal 6-81
female post-menopausal 14-186
(all in µg/L)
Alpha-1-anti-trypsin 1.5 g/L 1.0 3.0 g/L
