EMQs in Clinical Medicine.pdf - Peshawar Medical College

204 Metabolic and endocrine disturbances
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A 28-year-old woman presents with chest tightness and anxiety attacks.
She is hypertensive and her ECG shows left ventricular hypertrophy.
Phaeochromocytoma is a tumour of the sympathetic nervous system that
occurs in the adrenals in 90 per cent of cases. Ten per cent of phaeochromocytomas
are malignant. Patients usually have evidence of significantly
raised blood pressure and present with a range of symptoms,
including headache, palpitations, chest tightness, blanching and anxiety
attacks. Surgical excision is the treatment of choice.
A 40-year-old woman is worried about her changing appearance and
deepening voice. On examination she has coarse oily skin, enlarged
tongue and proximal muscle weakness. She also mentions paraesthesia
in both hands of recent onset.
Acromegaly is caused by over-secretion of growth hormone (GH) from a
pituitary adenoma. Most patients present with symptoms of change in
appearance (particularly skin changes) or symptoms associated with mass
effect of the tumour, e.g. headache, visual field defects. There are many
changes in appearance caused by growth of soft tissues. Macroglossia
and spade-like hands are particularly sensitive indicators of the presence
of disease. Acromegaly is associated with hypertension, diabetes mellitus
and cardiomyopathy with death usually occurring as a result of cardiovascular
pathology. The oral glucose tolerance test is diagnostic. Patients
with acromegaly fail to suppress GH and indeed there may be a paradoxical
rise in GH levels. Trans-sphenoidal surgical excision is the treatment
of choice.
79 Nutritional deficiencies
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A 30-year-old woman with poor diet complains of bleeding gums.
Vitamin C is involved in the hydroxylation of proline to hydroxyproline,
which is necessary for the normal formation of collagen. In this scenario
vitamin deficiency has led to scurvy.
A 55 year old with alcohol problems presents with nystagmus, ophthalmoplegia
and ataxia.
This triad of symptoms is a sign of Wernicke’s encephalopathy. Urgent
thiamine is required to treat this condition to prevent progression to
Korsakoff’s syndrome. This is an irreversible condition characterized by
anterograde and retrograde amnesia, resulting in confabulation.
A 35-year-old patient recently diagnosed with coeliac disease complains
of prolonged bleeding after a small cut. The prothrombin time is
increased.