About the Book

A lot of updation incorporated in each chapter.
The first two chapters are completely rewritten.
Two new chapters dealing with CNS pathology and problem cards respectively are also included.
Point-wise arrangement of steps to avoid confusion.
It would help young students of pathology to discover the actual patients behind the problems, paving the step of their future success in clinical practice.

About the Author

Sanjay Sengupta MBBS, DTM & H, MD (Pathology)

Table of Contents:
Chapter 1: Cardiovascular System 1 CQ1. A 9-year-old girl from an urban slum seeks medical attention for fever with pain and swelling of both knee and right wrist joints, affected one after another during last 7 days. 1 • What is your provisional diagnosis? • What are other possibilities? • How do you investigate the case? – Acute rheumatic fever – Juvenile idiopathic arthritis – Septic arthritis – Valvular heart disease – Mitral valve slenosis CQ2. A 15-year-old boy complaining of palpitation and breathlessness for 1 week. O/E: Fever with tender swelling of left elbow joint; right ankle joint was similarly affected 4 days ago. H/o sore throat 3 weeks before. 8 • What is your provisional diagnosis? • How will you confirm your diagnosis? CQ3. A 5-year-old girl is admitted into hospital with jerky, irregular, uncontrolled movement of both hands for 7 days. There was an attack of febrile polyarthritis involving both elbow and ankle joints about 1 month before. 8 • What is the most likely diagnosis? • How will you proceed for confirmation of diagnosis? CQ4. A boy, aged 16-year-old comes with fever and migratory polyarthritis for 1 week. He is also complaining of palpitation, respiratory distress and chest pain. 9 • What are the possible causes? • How will you proceed for diagnosis? – Lyme disease CQ5. A 28-year-old female comes to outdoor with gradually increasing respiratory distress, palpitation and cough for 1 year. On enquiry, past H/o multiple attacks of febrile polyarthritis. 10 • What are the probable causes? • How will you investigate the case? – Chronic rheumatic heart disease – Cardiomyopathy – Constrictive pericarditis – Primary pulmonary hypertension – Rheumatoid heart disease – Pericarditis Contents CQ6. A middle-aged man is complaining of gradually increasing respiratory distress, chronic cough, palpitation, and pedal edema with occasional hemoptysis for last 3 years. He admits multiple attacks of polyarthritis during childhood. 18 • What is your provisional diagnosis? • How will you confirm it? CQ7. A 25-year-old male patient gets admitted into hospital with low-grade, irregular fever for more than 6 weeks. Patient also complains of fatigue, lassitude, palpitation and respiratory distress. Careful history taking unmasks two additional features: – Presence of gradually increasing breathlessness for last 2 years. – Past history of multiple attacks of febrile polyarthritis during childhood 18 • What are the possible causes? • How will you proceed for diagnosis? – Subacute bacterial endocarditis – Infective endocarditis CQ8. A 65-year-old male, living in a slum, alone, comes to outdoor with fatigue, weight loss and malaise for 2 months. Patient is also suffering from chronic cough, occasional hemoptysis and slowly progressive breathlessness for years. O/E: Mucocutaneous petechial spots and subungual hemorrhages seen. 22 • What is your provisional diagnosis? • What can be other possibilities? • Describe the steps for confirmation of diagnosis. CQ9. A 48-year-old male is complaining of sudden onset severe retrosternal chest pain, diaphoresis and respiratory distress. O/E: Rapid and feeble pulse with cold extremities. 22 • What are the possible causes? • How will you pinpoint your diagnosis? – Myocardial infarction – Pulmonary embolism with infarction – Aortic dissection – Tension pneumothorax – Acute bacterial pneumonia – Acute pancreatitis (brief) – Ischemic heart diseas – Atherosclerosis – Hypertensive vascular diseases – Health hazards of tobacco CQ10. A 39-year-old male smoker with hypertension suddenly develops severe left sided chest pain with extension to left arm, sweating, respiratory distress and syncopal attack. 45 • What are the possibilities? • How will you investigate the case? CQ11. A 65-year-old diabetic male gets admitted into hospital with mild retrosternal discomfort, breathlessness, tachycardia and progressively falling blood pressure for 3 hours. 45 • What is the most likely diagnosis? • How will you establish your diagnosis? xiv Problem-based Questions in Pathology CQ12. A 56-year-old female, in the postoperative period, suddenly developed severe chest pain, breathlessness, cough with hemoptysis and pyrexia. 45 • What is your provisional diagnosis? • How will you proceed for diagnosis? CQ13. A 33-year-old male smoker comes to surgical outdoor with severe pain in both lower limbs, particularly during walking, with bilateral wasting of calf muscles and ulceration over right great toe. 45 • What is your provisional diagnosis? • How will you justify your diagnosis? – Buerger’s disease CQ14. A 56-year-old male, complaining of severe headache over right temporal region for 3 months, suddenly developed dimness of vision of right eye. O/E: Dilated, tender blood vessel over temporal region. 46 • What is the most likely diagnosis? • How will you investigate the case? – Temporal arteritis CQ15. A 25-year-old young femal seeks medical attention with coldness and numbness of fingers, vertigo and dimness of vision. O/E: Radial pulse on both upper limbs very weak. 47 • What is your diagnosis? • How will you establish your diagnosis? – Takayasu’s arteritis CQ16. A 30-year-old female presenting with a small, elevated, firm and tender nodule, reddish in color, at the subungual region of left second finger. 48 • What is your provisional diagnosis? • How will you confirm your diagnosis? – Glomus tumor CQ17. A 36-year-old homosexual male, HIV +ve for 7 years, developed rapidly progressive multiple reddish nodules over ankle and calf of right leg with right popliteal and inguinal lymphadenopathy. 48 • What are those lesions? • How can you confirm the diagnosis? – Kaposi’s sarcoma CQ18. Teenage girl comes for consultation with excessive pain and swelling of both knee and elbow joints for a week. H/o cold, cough, fever and throatache 2 weeks prior to onset of presenting symptoms is present. 50 • What is your provisional diagnosis? • What can be other possibilities? • How will you approach for diagnosis? CQ19. A 39-year-old female, presented with slowly developing breathlessness, chronic cough and occasional hemoptysis for last 3 years. Past H/o repeated attacks of joint swellings with fever during childhood. 50 • What are the possible causes? • Discuss lab investigations for confirmation of your diagnosis. CQ20. A 56-year-old male, smoker and hypertensive, complaining of severe pain in the left side of chest with sweating, palpitation and respiratory distress for 1 hour. 50 • What are the probable causes? • Describe the steps for diagnosis. Contents xv Chapter 2: Respiratory System 51 RQ1. A 52-year-old male, smoker comes to outdoor with cold, cough, fever, respiratory distress and profuse expectoration for 3 days. Previous history of similar attacks during last 2 years is present. 51 • What are the possible causes? • How will you proceed for diagnosis? – Chronic bronchitis – Bronchial asthma – Bronchiectasis – Lung abscess – Acute bacterial pneumonia RQ2. A 68-year-old male, smoker presented with gradually increasing respiratory distress for last 1 year with cough, scanty expectoration, and weight loss. 61 • What are the possibilities? • How will your confirm your diagnosis? – Emphysema – Interstitial lung disease – Pulmonary tuberculosis RQ3. A 28-year-old female presented with recurrent episodes of cough, wheezing and respiratory distress for more than 2 years. 71 • What is the possible cause? • What can be other possibilities? • How will you proceed for laboratory investigation of the case? – Acute left ventricular failure RQ4. A middle-aged man came for medical attention with recurrent attacks of fever, weight loss, chest pain, chronic cough, expectoration of foul smelling sputum and clubbing for more than 2 and half years. 73 • What are the possible causes? • How will you investigate the case? RQ5. A 5-year-old male child admitted into pediatric ward with high fever, chest pain, palpitation, respiratory distress and expectoration of rusty sputum for 2 days. 74 • What is your provisional diagnosis? • How will you investigate the case? RQ6. A 75-year-old male suffering from bronchogenic carcinoma of left lung developed high fever, chest pain, respiratory distress with productive purulent foul smelling expectorate within a short period. 75 • What is the most possible complication developed in this case? • What are other possibilities? • How will you proceed to diagnose the complication? RQ7. Female patient, aged 53-year-old presented with low-grade fever, chest pain, weight loss and occasional hemoptysis for last 4 months. 75 • What are the possibilities? • How will you diagnose the case? – Bronchogenic carcinoma – Metastatic lung tumor – Lymphoma of lung xvi Problem-based Questions in Pathology RQ8. A 32-year-old adult male seeks medical attention for gradually increasing breathlessness, fever, cough, and occasional hemoptysis with right-sided pleural effusion. 81 • What is the possible diagnosis? • What can be other possibilities? • How can you confirm your diagnosis? RQ9. A 60-year-old male smoker is complaining of dry cough, occasional hemoptysis, chest pain, anorexia, weight loss and clubbing for 5 months. 81 • What is your provisional diagnosis? • How will you establish your diagnosis? RQ10. A 58-year-old male smoker working in an asbestos factory for 30 years, comes to outdoor with chest pain, weight loss, chronic cough, occasional hemoptysis and shortness of breath for 3 months. O/E: There is shifting of trachea towards left side with dull percussion note over right side of chest. 81 • What are the possibilities? • How will you progress for confirmation of diagnosis? – Malignant mesothelioma – Benign mesothelioma – Asbestosis with pleural effusion RQ11. A middle-aged female complaining of chronic cough, chest pain, and shortness of breath for more than 1 year. Chest X-ray—Bilateral hilar lymphadenopathy. 86 • What is your provisional diagnosis? • What other possibilities should come into consideration? • How will you confirm your diagnosis? – Sarcoidosis RQ12. A 32-year-old female complains of intermittent attacks of diarrhea, cyanosis and flushing for 4 years, along with repeated attacks of bronchoconstriction. She is also complaining of dry cough and occasional hemoptysis during this period. Chest X-ray shows a small, circumscribed nodule in the left lung. 89 • What is the most possible diagnosis? • How will you proceed for confirmation of your diagnosis? – Bronchial carcinoid RQ13. A 45-year-old male presents with a small, smooth rounded mass shadow on routine chest X-ray. There is no accompanying symptom. 90 • What is the most probable diagnosis? • How will you confirm the diagnosis? – Lung hamartoma RQ14. A 50-year-old male, nonsmoker, seeks medical attention for cough with expectoration, often blood tinged, weight loss, anorexia, chest pain and evening rise of temperature for 3 months. 91 • What is your provisional diagnosis? • What can be other possibilities? • Describe the steps for confirmation. RQ15. A 29-year-old young femal was admitted to hospital with cough, occasional hemoptysis, low-grade fever and slowly developing breathlessness for more Contents xvii than 1 year. O/E: Bilateral iritis, parotitis, cervical lymphadenopathy and hepatosplenomegaly. 91 • What are the possibilities? • How will you confirm your diagnosis? – Sjögren’s syndrome RQ16. A 58-year-old female seeks medical attention for dry cough, occasional hemoptysis, chest pain, and weight loss for last 6 months. Chest X-ray shows single large irregular opacity on peripheral portion of lower lobe of right lung 92 • What is your provisional and differential diagnosis? • Describe steps for confirmation of your diagnosis. RQ17. A 72-year-old male, smoker, gets admitted with dry cough, occasional hemoptysis, chest pain, anorexia, and weight loss for last 2 months. O/E: Vague lump in the right iliac fossa along with hard right supraclavicular lymph node. 93 • What is the most likely diagnosis? • What are other possibilities? • Describe steps for confirmation of diagnosis. RQ18. A 73-year-old male, heavy smoker for more than 30 years, developed chronic cough, hemoptysis, chest pain, and weight loss for last 3 months.CT scan of the lung shows a large central shadow with irregular, infiltrating margins. Blood biochemistry shows hypercalcemia 93 • What is your provisional diagnosis? • How will you approach for confirmation? RQ19. A 68-year-old male, smoker, presented with breathlessness, cough, and chest pain for 2 months. O/E: Ptosis with puffy face, swelling, and congestion of upper part of chest and neck, hoarseness of voice, clubbing along with tender swelling of right wrist joint. 93 • What is the most likely diagnosis? • How can you explain all the features? • What are other causes and how will you proceed for diagnosis? – Thymoma RQ20. A 72-year-old female, presented with intense chest pain, anorexia, weight loss, cough with occasional hemoptysis for 1 month. She also complained of intermittent flushing and diarrheal attacks. O/E: Muscular weakness and peripheral neuropathy of both lower limbs seen. Serum electrolyte study showed hyponatremia. 95 • What is your provisional diagnosis? • What can be other possibilities? • How will you confirm your diagnosis? RQ21. A 50-year-old male, smoker, with weight loss, chest pain, cough, and hemoptysis for 3 months. Chest X-ray: Large SOL at central portion of left lung. 95 • What is your provisional diagnosis? • How will you confirm your diagnosis? RQ22. A 27-year-old female, nonsmoker, complaining of chronic cough, night sweat, weakness, slowly developing breathlessness and cervical lymphadenopathy. 95 • What are the possibilities? • How will you investigate the case? xviii Problem-based Questions in Pathology RQ23. A middle-aged man with long-standing diabetes presented with low-grade fever for 2 months with chronic cough and occasional hemoptysis. 95 • What is your provisional diagnosis? • What are other possibilities? • Describe steps for diagnosis. RQ24. A 59-year-old male, working in sand blasting, gradually developed shortness of breath with chronic cough. 95 • Chest X-ray showed fine nodular shadows in the upper part of both lungs. • What are the possible causes? • How can you confirm your diagnosis? RQ25. A 9-year-old female child presented with sudden onset of fever with chill and rigor, chest pain, cough, and respiratory distress. 95 • What is the most likely diagnosis? • What should be your approach for confirmation of diagnosis? Chapter 3: Gastrointestinal Tract, Hepatobiliary System and Pancreas 96 GQ1. A middle-aged alcoholic male gets admitted into emergency ward with epigastric pain and hematemesis for 24 hours. He admits frequent attacks of pain particularly during empty stomach in the recent past. 96 • What is your provisional diagnosis? • What can be other possibilities? • How will you confirm your diagnosis? – Peptic ulcer – Zollinger-Ellison syndrome – Gastric carcinoma – Acute gastric ulcerations – Bleeding esophageal varices – Cirrhosis of liver – Esophageal tear GQ2. A36-year-oldmale comes to emergencywithsevere epigastricpainandvomiting for 5 hours. 107 • What are the possibilities? • How will you investigate the case? – Acute pancreatitis (detailed including pancreatic pseudocyst) – Acute cholecystitis – Chronic cholecystitis GQ3. A middle-aged female seeks medical attention for a lump in the epigastric region with anorexia and vomiting for 3 months. 114 • What can be the possibilities? • What will be your line of approach for correct diagnosis? – Metastatic liver tumors – Hepatocellular carcinoma – Carcinoma of gallbladder – Carcinoma of the pancreas GQ4. A 66-year-old female presents with anorexia, weight loss and weakness for 6 months. There is also history of hematemesis. O/E: There is a palpable lump over epigastric region. 118 • What is your provisional diagnosis? • What are other possibilities? • How will you investigate the case? Contents xix GQ5. A 63-year-old female comes to outdoor with fatigue, weight loss, anorexia and weakness of both lower limbs for 3 months. O/E: There is a palpable lump over epigastric region. Routine blood examination shows: Low hemoglobin concentration and hypersegmented neutrophils with macro-ovalocytes. 118 • What is your provisional diagnosis? • How will you confirm your diagnosis? GQ6. A 39-year-old female presented with fever associated with chill and rigor and tender hepatomegaly. 119 • What are the causes? • How can you confirm your diagnosis? – Amebic liver abscess – Pyogenic liver abscess – Ascending cholangitis GQ7. A 49-year-old female complaining of nausea, anorexia, and pain abdomen for last 6 months. O/E: There is tenderness with a lump in the right hypochondrial region. 121 • What are the possibilities? • How can you confirm your diagnosis? GQ8. A 36-year-old male presenting with anorexia low-grade fever, vomiting, pain abdomen and yellowish discoloration of urine for 1 month. 123 • What is the most probable diagnosis? • What are other possibilities? • How will you proceed for diagnosis? – Infective hepatitis – Choledocholithiasis – Jaundice GQ9. A 63-year-old male patient presents with anorexia, weight loss and dysphagia to solid food for last 2 months. He also admits occasional bouts of hematemesis in recent past. 136 • What is your provisional diagnosis? What can be other possibilities? How will you confirm your diagnosis? – Malignant tumors of esophagus – Reflux esophagitis GQ10. A 58-year-old male presents with ascites, pedal edema, anorexia, weight loss, muscle wasting of the extremities for last 4 years. He also complains of three attacks of hematemesis and malena during last 1 year. 139 • What are the possible causes? How can you confirm your diagnosis? – Alcoholic liver disease (fatty liver, alcoholic hepatitis, alcoholic cirrhosis) – Adverse effects of alcohol GQ11. A 32-year-old female gets admitted into medicine ward with anorexia, vomiting and ascites for 1 year. On enquiry there is intense pruritus, deep yellow urine and clay colored stool. O/E: There is hepatosplenomegaly. 147 • What are the possibilities? • How will you investigate the case? – Primary biliary cirrhosis – Secondary biliary cirrhosis – Primary sclerosing cholangitis xx Problem-based Questions in Pathology GQ12. A 23-year-old male presents with fluctuating hyperbilirubinemia, predominantly unconjugated, for years without illness. 151 • What is your provisional diagnosis? • What may be other possibilities? • How can you confirm your diagnosis? – Gilbert’s disease – Crigler-Najjar syndrome – Dubin-Johnson syndrome – Rotor’s syndrome – Hemolytic jaundice GQ13. A 22-year-old male presented with fatigue, weight loss, bouts of low-grade fever, anorexia and multiple attacks of jaundice for last 3 years. O/E: There was tender hepatomegaly. 153 • What are the possible causes? • How will you confirm your diagnosis? – Wilson’s disease – a1 antitrypsin deficiency (hepatic injury) – Drug-induced hepatitis – Autoimmune hepatitis GQ14. A 8-year-old male child admitted into pediatric ward with anorexia, nausea, weight loss and ascites for 1 year. O/E: Spleen is enlarged with presence of dilated veins over anterior abdominal wall. 158 • What are the possible causes? • How will you investigate the case? – Indian childhood cirrhosis GQ15. A 53-year-old female presented with hepatomegaly. Ultrasonography showed a single large mass on right lobe of liver. 160 • What can be the possibilities? • How will you investigate the case? – Hydatid cyst GQ16. A 41-year-old fatty female presented with nausea, vomiting, indigestion and right upper abdominal pain for 7 days. Past H/o frequent attacks of similar symptoms during last 2 years. 163 • What is your provisional diagnosis? • What are other possibilities? • How will you confirm the case? – Chronic gastritis GQ17. A 28-year-old male presents with frequent passage of bulky, frothy, greasy stool with abdominal distension, muscle wasting, fatigue and weight loss for more than 1 year. 165 • What are the possible causes? • How can you confirm your diagnosis? – Celiac disease – Tropical sprue – Whipple disease – Giardia lamblia infection – Crohn’s disease Contents xxi GQ18. A 4-year-old male child presents with anorexia, loss of weight, failure to thrive and frequent passage of bulky, frothy stool with abdominal distension and indigestion for more than one year. 173 • What can be the possible causes? • Give an outline for confirmation of your diagnosis. – Malnutrition-related malabsorption – Lactase deficiency – Abetalipoproteinemia – Cystic fibrosis GQ19. A 36-year-old female presents with frequent attacks of diarrhea, weight loss, fever and abdominal pain for last 3 years. 177 • What are the possible causes? • How will you investigate the case? – Ulcerative colitis – Irritable bowel syndrome GQ20. A 33-year-old female is admitted into emergency ward for frequent bouts of bloody diarrhea with tenesmus and toxic features. H/o similar attacks twice during last 1 year are reported. 184 • What are the possible causes? • How will you confirm your diagnosis? – Bacillary dysentery – Ischemic bowel disease GQ21. A 58-year-old male presenting with weakness, fatigue, weight loss and alteration of bowel habit for more than 6 months. O/E: There is pallor. Stool for occult blood test: (+) ve. 188 • What are the possible causes? • How will you investigate the case? – Colorectal carcinoma – Carcinoid tumor – GI tract lymphomas – Colorectal polyps – Hookworm infestation GQ22. A 63-year-old male presented with alternate attacks of diarrhea and constipation for 3 months with an ill-defined vague lump in the iliac fossa. 198 • What are the possible causes? • How will you confirm your diagnosis? – Ileocecal tuberculosis GQ23. Teenage girl comes to emergency with acute pain in the right iliac fossa with vomiting and fever for 12 hours. 200 • What are the possible causes? • How will you proceed for diagnosis? – Acute appendicitis – Meckel’s diverticulitis – Amebic colitis – Acute salpingitis – Ovarian torsion – Acute cystitis xxii Problem-based Questions in Pathology GQ24. A 72-year-old male admitted into emergency ward with pain in the right lower abdomen and vomiting. O/E: There is an ill-defined mass in the right iliac fossa. 205 • What are the possible causes? • How can you confirm your diagnosis? GQ25. A 69-year-old male presented with anorexia, weight loss and pallorfor 6 months. O/E: There was hepatomegaly and a vague, ill-defined mass in the right lower abdomen. 206 • What is your provisional diagnosis? • How can you investigate the case? GQ26. A 59-year-old male and known alcoholic, complains of gradual swelling of abdomen and pedal edema for 2 years. There was about of hematemesis 2 months back. 206 • What is your provisional diagnosis? • How will you investigate the case? GQ27. A 71-year-old male seeks medical attention for recent development of constipation for 1 month. He is suffering from weakness, fatigue and anorexia for 6 months. O/E: Pallor, palpable liver and a vague lower abdominal mass. 206 • What is your provisional diagnosis? • How can you confirm your diagnosis? GQ28. Teenage girl comes to you with anorexia, nausea, vomiting and fever for 3 days. She also complains of yellowish discoloration of urine. 206 • What are the possible causes? • How will you approach for diagnosis? GQ29. A70-year-old male patient presents with anorexia, weightloss,fatigue and upper abdominal pain for 2 months. O/E: Liver is palpable with sharp margin. 206 • What can be the possible etiologies? • What should be your line of investigation? GQ30. A 25-year-old female gets admitted into emergency ward with bloody dysentery, pain abdomen and features of shock. 207 • What are the possible causes? • How will you reach diagnosis? GQ31. A 56-year-old male smoker is complaining of acidity and pain upper abdomen for 1 year. He has one attack of hematemesis. 207 • What are the likely causes? • How will you investigate the case? GQ32. A 5-year-old girl presents with ascites and pedal edema for 1 year. O/E: There is splenomegaly. 207 • Enumerate possible causes. • Discuss the investigations you want to perform for confirmation of diagnosis. GQ33. A 20-year-old male presented with fever, upper abdominal pain, anorexia, nausea and yellowish discoloration of urine for 5 days. 207 • What is your provisional diagnosis? • How will you propose to investigate the patient? Chapter 4: Genitourinary System 208 GUQ1. A 40-year-old male presents with weakness, fatigue, polyuria, hypertension and occasional hematuria for 3 years. O/E: Bilateral abdominal lumps atflanks. 208 • What are the possible causes? Contents xxiii • How will you investigate the case? – Adult polycystic kidney – Childhood polycystic kidney disease – Most common causes of hydronephrosis – Renal calculi GUQ2. A 6-year-old girl comes to outdoor with puffy face, pedal edema, oliguria and hematuria for 1 week. O/E: There is hypertension. 214 • What is your provisional diagnosis? • What can be other causes? • How will you investigate the case? – Acute (poststreptococcal) proliferative glomerulonephritis – Nonstreptococcal glomerulonephritis – Rapidly progressive glomerulonephritis – IgA-nephropathy (Berger’s disease) GUQ3. A4-year-oldboy isbroughttoyouwithgeneralizedswellingofthebody (anasarca) for 5 days. Urine examination shows marked proteinuria. 219 • What is your provisional diagnosis? • Enumerate the causes and how will you confirm your diagnosis? – Lipoid nephrosis (minimal change glomerulonephritis) – Membranoproliferative glomerulonephritis – Membranous glomerulonephritis – Focal segmental glomerulosclerosis GUQ4. A 42-year-old female admitted into hospital with anasarca and hypertension for 2 weeks. Routine urine examination shows massive proteinuria. 226 • What is your provisional diagnosis? • What are the causes of development of this disease? • How will you establish the etiology? – Diabetes mellitus – Amyloidosis – Systemic lupus erythematosus (SLE) GUQ5. A 33-year-old female comes to outdoor with generalized swelling of the body. O/E: There are malar rashes, photosensitivity, pain and swelling of both knee joints. Routine urine examination shows heavy proteinuria. 253 • What is the possible diagnosis? • How will you investigate the case? GUQ6. A 29-year-old male presented with anasarca and heavy proteinuria. On enquiry, there was long standing H/o diabetes mellitus. 254 • What is your diagnosis? • How will you confirm your diagnosis? GUQ7. A 53-year-old female, suffering from rheumatoid arthritis for more than 15 years, gradually develops difficulty in articulation, anasarca and heavy proteinuria. O/E: There is macroglossia and irregular pulse rate. 254 • What is the possible diagnosis? • How will you confirm it? GUQ8. A 42-year-old female presents with hematuria, proteinuria, hypertension and hemoptysis for 2 weeks. 254 • What is your provisional diagnosis? • What are other causes? • How will you confirm your diagnosis? – Wegener’s granulomatosis – Malignant hypertension – Renal cell carcinoma with metastasis to lung xxiv Problem-based Questions in Pathology GUQ9. A 15-year-old girl complains of acute abdominal pain, knee joint swelling, hematuria and purpuric rashes over buttock. 261 • What is the provisional diagnosis? • What can be other possibilities? • How will you confirm your diagnosis? – Henoch-Schönlein purpura GUQ10. A 30-year-old male is presenting with severe oliguria, hypertension and edema for last 24 hours. H/o hematuria for 2 weeks; patient was symptomless 2 weeks back. 262 • What is your provisional diagnosis? • What will be your approach for confirmation of diagnosis? – Rapidly progressive glomerulonephritis (RPGN) GUQ11. A 63-year-old male presents with slowly progressive weakness, anorexia, fatigue and weight loss for 1 year. O/E: There is edema and hypertension. Investigation: Urine protein ++; Blood urea – 86 mg%; Serum creatinine – 3.2 mg% 263 • What is your provisional diagnosis? • What are the most common causes? • How will you differentiate the conditions? – Chronic glomerulonephritis – Chronic pyelonephritis – Analgesic abuse nephropathy GUQ12. A 51-year-old male admitted to emergency ward with anuria for 24 hours following an attack of diarrhea and vomiting for 3 days. 268 • What can be the possibilities? • How will you investigate the case? – Acute tubular necrosis (ATN) – Hemolytic-uremic syndrome (HUS) GUQ13. A 36-year-old female presents with fever associated with chill and rigor, malaise, vomiting, dysuria, frequency and pain at right costovertebral angle for 5 days. 271 • What can be the possibilities? • How will you investigate the case? – Acute pyelonephritis GUQ14. A 28-year-old female presenting with fever, accompanied by chill and rigor, vomiting, dysuria, hematuria and severe pain in the lower abdomen for 24 hours. 273 • What are the possible causes? • How will you investigate the case? – Ureteric calculi – Lower urinary tract infection GUQ15. A 54-year-old male presented with repeated attacks of hematuria for last 6 months. 275 • What are the possible causes? • How will you confirm your diagnosis? – Renal tuberculosis – Carcinoma of urinary bladder GUQ16. A 63-year-old male presents with recurrent hematuria for last 3 months with mild left costovertebral pain. O/E: There is a palpable swelling at left flank. 280 • What is your provisional diagnosis? • What can be the differential diagnosis? • How can you investigate the case? Contents xxv GUQ17. A 52-year-old male presents with intermittent hematuria for 3 months with attacks of frequency and dysuria. 280 • What are the possible causes? • How will you investigate the case? – Chronic prostatitis – Acute prostatitis – Chronic cystitis – Acute cystitis – Hunner’s ulcer – Cystitis glandularis – Malakoplakia GUQ18. A 53-year-old male presented with painless hematuria for 4 months along with rapidly developing left sided varicocele. O/E: There is a lump over left flank. 283 • What is your provisional diagnosis? • How will you confirm your diagnosis? GUQ19. A 3-year-old male child is brought to pediatric outdoor with rapidly increasing abdominal lump for 2 months. Associated symptoms are fever, hematuria and weakness. 283 • What is your provisional diagnosis? • What can be other possibilities? • How will you investigate the case? – Wilm’s tumor – Neuroblastoma – Rhabdomyosarcoma arising from lower genitourinary tract GUQ20. A 46-year-male comes with an elevated, ulcerated lesion over glans penis, present for 2 months. 288 • What are the possible causes? • How can you confirm your diagnosis? – Invasive carcinoma of penis – Verrucous carcinoma of penis – Carcinoma in situ of penis – Condyloma acuminatum – Syphilis GUQ21. A 5-year-old male comes to outdoor with a nontender, small right-sided inguinal swelling present since birth. O/E: Right scrotal sac is empty. 294 • What is your provisional diagnosis? • What are the investigations you want to perform for confirmation? – Cryptorchidism GUQ22. A 16-year-old male comes to outdoor with high fever and bilateral testicular swelling for 2 days. On enquiry, there is H/o fever and bilateral parotitis 1 week back. 295 • What is your provisional diagnosis? • How can you confirm your diagnosis? – Mumps and mumps orchitis GUQ23. A 56-year-old male presents with a cauliflower-like growth with central ulceration over glans penis for 2 months. O/E: The mass is nontender. There are also two discrete firm lymph nodes in the left inguinal region. 297 • What is your provisional diagnosis? • How will you confirm your diagnosis? xxvi Problem-based Questions in Pathology GUQ24. A male aged 63-year-old seeks medical attention for urinary frequency, nocturia, dysuria and sense of incomplete evacuation of bladder for last 6 months. 297 • What is your provisional diagnosis? • What can be other possibilities? • How will you proceed for confirmation? – Nodular hyperplasia of prostate – Carcinoma of the prostate GUQ25. Old man, aged 75 years, complains of back pain and frequency. Rectal examination shows presence of hard nodular areas over prostate. PSA: 8.9 ng/ ml. 302 • What is your provisional diagnosis? • What can be other possibilities? • How will you investigate the case? GUQ26. A 39-year-old male presents with a rapidly increasing right inguinal mass for 3 months. On enquiry, he admits presence of a small swelling at the same site since birth. O/E: Right scrotal sac is empty. 303 • What is your provisional diagnosis? • How will you confirm your diagnosis? – Testicular tumors GUQ27. A 63-year-old male presents with left supraclavicular hard lymph node, noted 2 weeks back. O/E: Hard, nonte