11 Exercises

1. Angola. A 30-year-old woman has open pulmonary tuberculosis. She weighs 50 kg. Treatment?
2. Zimbabwe. A woman was previously given long-term treatment for a "lung problem". She has since had disturbance of equilibrium and her hearing is not good. Could this be a side effect of oral medication?
3. Pakistan. A man with tuberculosis has been following his therapy for 7 months (INH, RMP, EMB for the first 2 months, and then INH and RMP). For the last 3 weeks he has walked with a strange gait. When he steps, he plumps his foot on the ground with a thud. He asks your advice. What do you think?
4. Mali. A man has had 6 weeks treatment for pulmonary tuberculosis and says that everything is looking more and more grey. What do you do?
5. Tanzania. One week after beginning therapy for pulmonary tuberculosis, a man comes to ask your advice because he apparently has a relapse of bilharziosis. What do you think?
6. Niger. A 57-year-old man has been coughing for quite some time. What do you think of an intradermal test for tuberculosis?
7. Uganda. A 24-year-old woman has been losing weight for some time. She has a cough and recently she has become short of breath. She has fever. She has been given cotrimoxazole, which brought an improvement, but she remains thin and in a generally fragile condition. She has pruritus and frequent, watery stools. A little while before the end of her therapy, she again begins to cough, she has fever and is short of breath. What do you think?
8. Sumatra. A Vietnamese boat refugee has had pain for some time on the right side of his neck. A surgeon noticed a local swelling. This was incised, but you do not know what was found. The man was sent home with penicillin. Two months later the lesion has still not healed. There are three swollen lymph nodes which can be felt, one of which has fluid draining to the skin. What do you think?
9. Tanzania. A 40-year-old woman is admitted with paralysis of both legs. This happened about two weeks ago. The legs are hypertonic. The patient has a fever of 38.7° . Why would you want to see the patient’s back? Would you want an X-ray? If so, which and why? Can this be poliomyelitis?
10. Rwanda. An emaciated man has been treated for some time for tuberculosis. During the treatment he developed oral sprue which was treated with gentian violet. He developed fever and neck stiffness. A lumbar puncture shows some rare round organisms. Could this be tuberculous meningitis? What do you think?
11. Give some information on the interaction of tuberculosis and AIDS.
12. Sudan. A 36-year-old African man who has travelled a great deal has complained for 2 months about significant loss of weight, anorexia and fever. He has several enlarged cervical lymph nodes. What diagnosis (or diagnoses) do you consider? (1) HIV infection, (2) kala azar, (3) West African trypanosomiasis, (4) lymph node tuberculosis, (5) Hodgkin’s lymphoma?
13. India. A 29-year-old man has a persistent cough. With Ziehl staining red rods are found in the sputum. After 5 weeks of tuberculostatics there is still no improvement. What are the possibilities?
14. Bhutan. You are shown a chest X-ray of a patient with right thoracic discomfort. The X-ray shows an homogenous greying of the right hemithorax. Classify the following possible diagnoses depending on the position of the mediastinum (to be evaluated from the position of the trachea and the heart): (a) large pleural effusion or empyema, (b) consolidation of the whole lung in severe pneumonia, (c) lung collapse (occlusion of main bronchus, e.g. carcinoma, mucus plug, foreign object).
15. Indonesia, Sulawezi. A 40-year-old woman is admitted with ascites. How would you differentiate between heart failure, liver failure with or without portal hypertension, nephrotic syndrome, tuberculous peritonitis, carcinomatosis of the peritoneum, rupture of lymph vessels to the peritoneum in Wuchereria bancrofti?
16. India. A 25-year-old man presents with a chronic swelling of the right ankle. You notice a small wound which secretes fluid upon compression. Do you think of chronic osteomyelitis with fistula, Madura foot or tuberculosis? Are there other possibilities? What do you do?
17. Zimbabwe. A pronounced pleural effusion is ascertained in a young man. If you were to carry out a pleural fluid aspiration, you might obtain transudate, exudate, purulent fluid or a bloody aspirate. Which diseases fit which result? (more than 1 possibility): heart failure, nephrotic syndrome, tuberculosis, pulmonary infarct, tumour (bronchus carcinoma, metastasis, mesothelioma), connective tissue disease (SLE, RA), pneumonia, high liver abscess, trauma.
18. Honduras. A 25-year-old patient has hilar lymphadenopathy on a chest X-ray. From these data, do you think initially of sarcoidosis, tuberculosis or a tumorous process? If the swelling is bilateral, does that make sarcoidosis more or less likely?
19. Congo. A 50-year-old white woman consults you because of recent mild painful, non-pruritic swollen red spots on both lower legs. The lesions are not ulcerating. Is this suggestive of erythema nodosum? What do you consider as a possible aetiology: sarcoidosis, streptococcal infection, tuberculosis, Yersinia enteritis, Crohn’s disease or ulcerative colitis, drug-reaction (sulfonamides, phenacetin, antipyrine, penicillin, salicylate)? What evidence are you going by? What do you think of the possibility of erythema nodosum leprosum?