Test your clinical acumen

(1) A patient of road accident feels violent pain on pressure by fingers on the tip of clavicle between sternomastoid and scleneus medius on the left side . What is  your diagnosis and what is the name of this point ?
Ans Splenic rapture and the point is called saegesser's splenic point.
(2) A lady of fifty has come, the only finding is her eighth costal cartilage on the right side is tender . Spot the diagnosis ?
Ans Cholecystitis .
(3) A child pulls at his prepuce at the time of micturation .
Ans Stone in the urinary bladder .
(4) Sudden increase in size with pain in cases of goitre .
Ans Haemorrhage in goitre. Although inflammatory swelling is also painful but onset is not sudden .
(5) A painter has come with intestinal colic ?
Ans Lead poisoning .
(6) A patient has come with a history of watery discharge at the time of meals having sinus over the ramus  of mandible .
Ans Parotid fistula .
(7) A patient of urinary retention with Argyll - Robertson pupil .
Ans Tables dorsalis .
(8) An adult female who was ill for months with wasting has come with  fracture of spine ?
Ams Pott's fracture .

Spot the Diagnosis-75

(1) A patient has come who has lost appreciation of temperature.
Ans :- Syringomyelia.
(2) A patient had spontaneous dislocation of his knee joint with a perforating ulcer of foot.
Ans :- Charcots joint.
(3) A child was brought by his parents.He has unilateral discharge from one nostril only.
Ans :- Foreign body in nose.
(4) A child of three years has come with one thigh in flexion, abduction and external rotation. He cannot say his complains. There is chill,hectic fever and tachycardia.
Ans :-Suppurative arthritis.
(5) In a child in spite of voracious appetite, there is wasting, has chronic cough and passes bulky and offensive smelling stool.
Ans :- Fibrocystic disease of panecreas.
(6) A patient complaints of pain during meal,hypersthecia of that side of face and gustatory sweating and unilateral facial flushing of that side.
Ans :-Frey's syndrome or auriculotemporal syndrome.
(7) A lady of fifty with swelling of thyroid feels cold.
Ans :-she may be a case of Myxoedema
(8) A lady of fifty with thyroid swelling feels hot.
Ans :-May be a case of thyrotoxicosis.
(9) A patient has a hard irregular and fixed tumour but the patient says it reduces sometime in size.
Ans :- Inflammatory swelling.
(10) A patient has huge enlargement of liver which is hard and irregular without palpable spleen.
Ans :- Secondary carcinoma of liver.

Spot the Diagnosis -74

(1) An infant was admitted with the complaints of cynosis, breathlessness on exertion and clubbing of all the fingers and toes. He squates on heels.
Ans :- Fallot's of tatralogy.
(2) A man having supraclavicular gland enlarged and he is suffering from carcinoma.
Ans :- Carcinoma of stomach or testis.
(3) A patient died of severe haematemesis. He had spider naevus on his chest and abdomen with ascites.
Ans :- Cirrhosis liver
(4) A patient having a hard lump in the epigastrium has virchow gland in left supra clavicular fossa.
Ans :- Carcinoma of stomach.
(5) A patient has come with the plum-coloured complection of his face with similar colouration of his tongue and mucous membrane.
Ans :-Polycythaemia rubra Vera.
(6) In a jaundice patient aged sixty five passes silver stool.
Ans :- Carcinoma of ampull of veter.
(7) A child has recovered from diarrhoea now he passes silver stool.
Ans :- It happens after sulphonamide therapy and in tropical sprue.
(8) A patient of seventy two years passes pipe stem stool.
Ans :-He may be a case of Carcinomatous stricture of rectum.
(9) A boy of acute abdominal pain passes red current jelly stool.
Ans :- Intussusception
(10) A patient of fifty has yellow raised patches on the inner canthus of both the eyes.
Ans :- Xanthelasma palpebrum due to persistant raised blood cholesterol.

Spot the Diagnosis -73

(1) An adult and obese lady   is a voracious eater.
Ans :- Hyperinsulism.
(2) A lady has come. She is very obese on trunk but not on limbs.
Ans :- Crushing syndrome.
(3) A fat boy who is found asleep and appetite regulation is not good.
Ans:-Hypopitutarism.
(4) A patient says that he is unable to hold water and his pupil is pin- point and slightly irregular.
Ans :- Tabes dorsalis.
(5) An adult male fifty has come with ptosis his W.R.is positive.
Ans :- Cerebro spinal syphilis.
(6) There is labial and circumoral pigmentations in a lady of twenty four years with intestinal polyposis.
Ans :- Peutz jigger syndrome.
(7) A patient was admitted in the ward with intermittent drooping of jaw along with ptosis.
Ans :- Myasthenia gravis.
(8) A patient has come with sunken eyes, slight icterus, watery conjunctiva and spider naevus on the front of chest and abdomen.
Ans :- Portal cirrhosis.
(9) Physical characteristics of a cervical lymph node leaves little doubt that the lymph nodes are malignant and you search for a primary in mouth, nose,ear,thyroid and lungs but you find it no where.where else you can think of.
Ans :- Branchiogenic carcinoma.
(10) A patient has come with an excruciating pain on the left lower thoracic region, muscular rigidity in the left hypochondrium and emphysema of the neck.
Ans :- Rupture of the oesophagus.

Spot the Diagnosis -72

(1) A lady patient of forty complaining pain in right hypocondriam and also tip of right shoulder.
Ans :- Acute cholecystitis.
(2) A patient of severe accident is complaining of severe pain and rigidity on her left hypochondrium and tip of left shoulder.
Ans :- Splenic rupture.
(3) A lady complaint of pallor and cyanosis occurring in the upper extremities on exposure to cold.
Ans :-Reynaud 's disease.
(4) A patient has come with swelling there is a pitting edema on pressure with brawny induration.
Ans :-Suppuration.
(5) A patient has come with ramshorn of his big toe nail.
Ans :- Anchylogryphosis.
(6) A patient on prolonged use of corticosteroids has developed mooning of his face.
Ans :- Iatrogenic crushing syndrome.
(7) Plum-colored complection with similar colouration of tongue and mucous membrane.
Ans :- Polycythaemia rubra Vera.
(8) A lady of fifty five has come with bogginess under the eyes,dry skin and non pitting edema.
Ans :- Myxoedema.
(9) A patient has come with bogginess under eye with the complaints of frequency and disurea.
Ans :- nephritis.
(10) A young lady came for cynosis of her whole face.she was taking sulphonamide.
Ans :- Sulphaemoglobinaemia

Spot the Diagnosis -71

(1) You are told that one patient with jaundice is suffering from carcinoma.
Ans :-Carcinoma of head of panecreas.
(2) One patient of jaundice with palpable gall bladder is suffering from carcinoma.
Ans :- Carcinoma of head of panecreas.
(3) A patient who was operated under spinal anesthesia has become unconscious.
Ans :- Cerebral abscess.
(4) A patient developed swelling from a mole.
Ans :- malignant melanoma.
(5) A patient has developed a chronic ulcer on the burn scar.The margin of the ulcer is raised an everted.
Ans :- Marjolin's ulcer.
(6) A patient has hard swelling it diminishes at times.
Ans :- Inflammatory swelling.
(7) A patient of carcinoma of breast has developed pain.
Ans :-It signifies complications such as ulceration, deep infiltration and nerve involvement.
(8) A patient has come with haematoma on the thenar  eminence and is unable to touch the little finger by his injured thumb.
Ans :- Bennett 's fracture.
(9) One Ramu Yadav fifty five consulted an M.D.for his abdominal distention pain and weakness. The doctor found one solitary renal cyst for which he was referred to AIIMS Delhi where he was admitted and all the test was done but no diagnosis was made his X-ray showed old healed tuberculosis which he suffered in his childhood. There is diffused tenderness all over his abdomen and complete anorexia and weakness.
Ans :- He may be a case of kock's abdomen. The doctors concentrated on the line of renal cyst.
(10) A patient has come with the complaints of locking his joint.On examination there is effusion in the joint.
Ans :- A loose body in his joint.

Spot the Diagnosis - 70

(1) A child has come with a swelling on the thoracic spine,he says the rigidity in the movement in the spine is the constant feature.
Ans :- Pott 's disease.
(2) A lady of thirtyfive has an ulcer which is punched out on the upper lip.
Ans :- Syphilitic ulcer.
(3) A patient of sixty has come with a lump in the abdomen with an enlarged left supra clavicular gland.
Ans :- Carcinoma of stomach.
(4) A patient has come with bony thickening with a sinus adhered to the bone.
Ans :- Osteomyelitis of the bone.
(5) A patient has come with a sinus with sprouting granulation tissue (proud flesh).
Ans :- Dead bone or foreign body inside.
(6) A patient has come with depressed sinus.
Ans :- Past suppuration.
(7) A lady of seventy has come with helpless evertion of lower limb and foot.
Ans :- Fracture of femoral neck.
(8) A patient lies curled up in bed on his side away from light.
Ans :- Cerebral irritation.
(9) what is the prognosis of a patient of carcinoma of breast having secondaries in bones.
Ans :- Bad prognosis.
(10) You are told that one patient has jaundice and stone some where.
Ans :- Stone in the common bile duct or pancreatic canculi.

Spot the Diagnosis -69

(1) A patient has come with painful intermittent jaundice.
Ans :-stone in the. Common bile duct.
(2) A patient has come with full  vein on the  side of umbilicus.
Ans :-Obstruction in the inferior venacava.
(3) A patient came with venous flow from  below upward.
Ans Obstruction in the  inferior venacava.
(4) A patient has come with hard subcutaneous nodules near the umbilicus.
Ans :-Carcinoma of stomach.
(5) A child has come with pain on the tip of penis accompanied by haematuria towards the end of micturition.
Ans:- stone in the bladder.
(6) A child has come with sudden screaming with pain and pulling at the prepuce at the time of micturition.
Ans :- Bladder stone
(7) A patient has come with scalding pain during micturition.
Ans :- Acute urethritis.
(8) An adult has come he says only straining improve the stream of urine.
Ans :- Stricture of urethra.
(9) An old man of fifty five says that straining retards the stream of urine.
Ans :- Enlarge prostate.
(10) A child has come with limping of legs, his extension of the hip is restricted.
Ans :- Tuberculosis of the hip joint.

Spot the Diagnosis -68

(1) An adult and obese lady   is a voracious eater.
Ans :- Hyperinsulism.
(2) A lady has come. She is very obese on trunk but not on limbs.
Ans :- Crushing syndrome.
(3) A fat boy who is found asleep and appetite regulation is not good.
Ans:-Hypopitutarism.
(4) A patient says that he is unable to hold water and his pupil is pin- point and slightly irregular.
Ans :- Tabes dorsalis.
(5) An adult male fifty has come with ptosis his W.R.is positive.
Ans :- Cerebro spinal syphilis.
(6) There is labial and circumoral pigmentations in a lady of twenty four years with intestinal polyposis.
Ans :- Peutz jigger syndrome.
(7) A patient was admitted in the ward with intermittent drooping of jaw along with ptosis.
Ans :- Myasthenia gravis.
(8) A patient has come with sunken eyes, slight icterus, watery conjunctiva and spider naevus on the front of chest and abdomen.
Ans :- Portal cirrhosis.
(9) Physical characteristics of a cervical lymph node leaves little doubt that the lymph nodes are malignant and you search for a primary in mouth, nose,ear,thyroid and lungs but you find it no where.where else you can think of.
Ans :- Branchiogenic carcinoma.
(10) A patient has come with an excruciating pain on the left lower thoracic region, muscular rigidity and the left hypochondrium and emphysema of the neck.
Ans :- Rupture of the oesophagus.

Spot the Diagnosis -67

(1) A patient of intestinal obstruction has come with rebound tenderness and  rigidity .
Ans Internal strangulation .

(2) A patient has come with board like abdominal rigidity with absence of liver dullness .
Ans Perforation of peptic ulcer .

(3) A patient of chronic bronchitis has come with loss of cardiac and liver dullness .
Ans Emphysema.

(4) A post operative patient was In the ward whose abdominal operation was done about three days ago has developed abdominal distention without visible peristalsis and silent abdomen .
Ans Paralytic ileus .

(5) A young patient has been admitted in the surgical ward with distention of the epigastrium and profuse and frequent vomiting with severe dehydration and terrible thirst .
Ans Congenital pyloric stenosis .

(6) A young patient has come with sudden and intense pain over the umbilicus and vomiting is incessant and offensive . There is central distension with ladder pattern peristalsis .
Ans Iow gut obstruction .

(7) A lady of forty has distaste for fatty food .
Ans She is likely to have gallbladder disease .(Qualitative dyspepsia)

(8) A man of fifty has loss of weight and appetite  and developed distaste for meat ?
Ans Early feature of gastric carcinoma .(qualitative dyspepsia)

(9)A man of forty five has come with the complaints of alternation in his bowel habits ,  alternate constipation and  diarrhoea  .
Ans May be a case of carcinoma of colon .

(10) A patient has come with painless progressive jaundice .
Ans May be a case of carcinoma head of pancreas.

Spot the Diagnosis -66

(1) A female has come with a splenic enlargement with mucocutaneous hemorrhage. Her platelet count is low.
Ans :- Idiopathic thrombocytopenic purpura haemorrhagica.

(2) A young patient with enlarged lymph nodes and evening raise of temperature has a lump in right iliac fossa.
Ans :- Ilioseacal tuberculosis.

(3) A patient of fifty has come with a lump in the right iliac fossa with the history of alternate diarrhoea and constipation and occult blood in the stool.
Ans :- Carcinoma of caecum.

(4) A gentleman of fiftyfive has come with multiple lumps in the abdomen. He has a family history of tuberculosis and he was also hospitalised twice and diagnosed as a case of chronic bronchitis.
Ans :- He may be a case of kock's abdomen.

(5) A patient has come with very hard and fixed lump in the right iliac fossa with multiple sinuses with sulphur granules.
Ans :- Actinomycosis of caecum and appendix.

(6) A lady patient has come with a very hard lump in the right iliac fossa. All doctors diagnosed it to be cancer of caecum. But one took his history she was ill with hectic fever and chill with pain in right iliac fossa. She was treated at that time with hard antibiotics and was cured.
Ans :- Antibioma.

(7) In a patient of obstruction distention is centrally in the abdomen.
Ans :-Small gut obstruction.

(8) A patient of obstruction has come with distention is periphery of abdomen.
Ans :- Large gut obstruction.

(9) A patient of obstruction has come with regional distension in the left lower region of abdomen.
Ans :- Volvulus of sigmoid colon.

(10) A patient of obstruction has come with tachycardia, elivated temperature and low blood pressure.
Ans :- Strangulation of gut.

Spot the Diagnosis -65

(1) A pyelogram of a patient has been shown to you . The pyelogram shows attenuated and elongated (spider leg ) calyeces with terminal clabbing or cupping of one kidney the other kidney is normal .
Ans:-Hypernephroma .

(2) Another patient has come with the same type of pyleogram with the only difference that the condition is bilateral .
Ans:-Polycystic kidney .

(3) You have diagnosed clinically a case of renal stone . Which type of x-ray would you like to do . Ultrasound, l.V.P and plane x-ray .
Ans:- Plane x-ray .

(4) An x-ray was shown to you in which there is a stone in the ureter and clubbing in the calyces .
Ans:- Hydronephrosis .

(5) An old man with urinary trouble has raised blood acid phosphates level .
Ans:-Prostatic carcinoma with metastasis in the bone

(6)  Unlike secondary in the bone there is osteosclerotic lesion .
Ans :-Primary carcinoma in the prostate secondary in the bone .

(7) An emaciated child has come with the history of passing faul smelling and  fatty stool.
Ans :- chronic panecreatitis.

(8) A patient of chronic pain abdomen has reported for a lump in the epigastrium.The lump is less mobile and more tender.
Ans :- A leaking gastric ulcer.

(9) A patient has come with splenic enlargement, jaundice and absence of bile from the urine and it's presence in his stool.
Ans :- Hemolytic jaundice.

(10) A patient of jaundice has come with bile in the urine and absence of bile in the stool.
Ans :- Obstructive jaundice.

Spot the Diagnosis-64

(1) A lady of fifty has come and there is a transverse furrow just above the iliac crest and her edge of the sacrum is prominent .
Ans Spondylolisthesis

(2) A lady aged about twenty has come with the complaints of high fever bilateral pain in the lower abdomen and tenderness with burning micturation .
Ans Acute salpingitis .

(3) A patient has been referred to a big hospital . The patient brings out faecal - smelling vomitus . Spot the diagnosis and speak of the prognosis ?
Ans It is the late case of intestinal obstruction and death is nearly certain .

(4) A patient has been seized with acute abdominal pain , vomiting and haematemesis associated with tender and rigid abdomen . He has murmur in his heart .
Ans Mesentric vascular occulucion.

(5) An old patient is admitted in the ward , he has hiccup and vomiting with abdominal distention . He has uriniferous smell in his breath . 
Ans Uraemic distension .

(6) A case of chronic amoebic liver  abscess was admitted in the ward. He has developed  severe headache , vomiting andy unconsciousness .
Ans :Metastatic cerebral amoebic   abscess .

(7) A case of subacute bacterial endocarditis was admitted in the medical ward for long . Suddenly he developed severe headache vomiting and became unconscious .
Ans Metastatic abscess in the brain .

(8) A case of lung abscess was admitted in the ward . Now he has developed headache , vomiting and drawsiness .
Ans Metastatic cerebral  abscess from lung.

(9) A patient of chronic otitis media has become unconscious , he had headache and vomiting .
Ans Metastatic cerebral abscess from ear .

(10) A chronic patient from Bronchiectasis became unconscious but there is no fever and tachycardia.
Ans Metastatic abscess of brain .

Spot the diagnosis -63

(1) A lady patient of thirty five of abdominal colic has come with deathly pallor and gasping respiration .
Ans Rupture ectopic gestation .

(2) A patient of abdominal pain has come with collapse and cynosis .
Ans Acute haemorrhagic pancreatitis .

(3) What is that disease in acute abdomen where pulse remains quite normal for quite a long time until its volume and tension fall and rate increases with no tendency to return to normal .
Ans Acute intestinal obstruction .

(4) A patient has come with acute abdomen and fever about 104F which system is involved .
Ans Probably abdomen is not involved . Look for other system .

(5) A patient has come with a severe pain in the epigastric region. There is a muscle guard on the upper half of right rectus . What do you think ?
Ans This is strongly suggestive of perforation of peptic ulcer .

(6) A patient of acute intestinal obstruction is admitted in the ward . He has developed early rigidity of abdominal wall . What do you think ?
Ans This is indicative of intestinal strangulation .

(7) A patient has come with abdominal pain on examination of his scrotum . There is swelling , redness and tenderness .
Ans Retroperitoneal lymphangitis .

(8) A lady of thirty five has been operated for L.S.C.S and discharged . After about two months she came with urinary incontinence and paraplegia  . All the doctors said that there must be some injury to the bladder .But when x-ray of the spine was done then the diagnosis became clear and vivid . Can you say what would have been there?
Ans There would have been Pott's fracture of the vertebra causing Pott's paraplegia  & incontinence .

(9) A Patient  of acute agonising abdominal pain , vomiting and lightening pain in the legs . One surgeon found Argyll Robertson pupil  and cleared the diagnosis . Can you say what disease was there of the patient ?
Ans Tabes dorsalis .

(10) A patient was hospitalised with agonising pain abdomen . Doctors failed to diagnose . Many test were done . His  serum amylase was much high .
Ans Acute pancreatitis.

Words of wisdom

A fool earns
More than thrice
And A cunning fellow
Befools him In a trice.
If the cunning fellow happens to be
A young and beautiful lady
there is a great threat not only
To his money and property
But also a threat to his life
And the life Of his wife.

Spot the Diagnosis -62

(1) In which disease on pressure on the left iliac fossa there is pain in the right iliac fossa.
Ans :-Inflamed appendix and this sign is known as Rovsing sign.

(2) what does it indicate when colicky pain of acute intestinal obstruction has changed to burning type.
Ans :-It indicates that peritonitis has set in.

(3) In case of acute appendicitis there is sudden disappearance of pain.
Ans:-It indicates perforation of gangrenous appendix.

(4) Sudden diminution of pain in peptic ulcer.
Ans :- It indicates perforation.

(5) A patient of abdominal trauma has come. He has tachycardia and shock like features with pain on the tip of left shoulder.
Ans :-Rupture of the spleen .(Kehr sign)

(6) A fatty lady of forty is having pain in abdomen with Nausea,vomiting and pain on the right shoulder.
Ans :- Acute cholecystitis.

(7) A case feels relief on his abdominal pain on pressure.
Ans :- He is having abdominal colic.

(8) A patient of abdominal pain feels aggravation of pain on pressure.
Ans :-Inflammatory pain.

(9) A patient has agonising pain but he gets relief when he sits up or lies down on his abdomen.
Ans:-Acute pancreatitis.

(10) A patient has come with lower chest pain. He says there is aggravation in pain when he takes deep inspiration.
Ans :-Diaphragmatic pleurisy.

Spot the Diagnosis -61

(1) An old patient has come with pain in the limbo-sacral region. An x-ray there is secondary metastases in bone which is osteosclerotic.
Ans :-Carcinoma of prostate.

(2) A child died in the traveling train while coming with his parents. There was severe bleeding from his ear.the boy had port-wine stain on his face.
Ans :-Sturge-weber syndrome.

(3) A patient has come with pain in right iliac fossa first,vomiting next and fever last of all.
Ans :- Murphy's syndrome. It happens in acute appendicitis.

(4) In a patient there is hypersthecia in sherren's triangle in abdomen. In which disease this happens.
Ans :-some surgeon thinks that this is the definitive sign of acute appendicitis.

(5) In a patient the sign of hypersthecia in sherren's triangle disappears the next day.
Ans:-It indicate brusting of the gangrenous appendix.

(6) In a diagnosed case of appendicitis the pain in right iliac fossa has shifted to the left iliac fossa.What does it indicate.
Ans :-Peritonitis has set in.

(7) The lady has come with pain abdomen. There is hypersthecia of 9-11 rib right side in the back.Can you name this sign and disease.
Ans:-Boas sign in acute cholecystitis.

(8) In a case of perforated peptic ulcer the muscle guard spreads from the right hypocondrium to right illiac fossa.
Ans :-As the gastric content gravitates down along the right para colic gutter.

(9) A patient admitted in the ward developed rebound tenderness.
Ans :-it is observed in any case of peritonitis.

(10) Appearance of rebound tenderness in a case of intestinal obstruction.
Ans :-It shows strangulation.