Problem-based Questions in

PATHOLOGY
Problem-based Questions in
PATHOLOGY

Sanjay Sengupta MBBS DTM & H MD (Pathology)

Assistant Professor, Pathology
Department of Pathology
Dr BC Roy Memorial Hospital for Children
Phoolbagan
Kolkata, India

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Problem-based Questions in Pathology
© 2010, Sanjay Sengupta
All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form
or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the
author and the publisher.

This book has been published in good faith that the material provided by author is original. Every effort is made to ensure
accuracy of material, but the publisher, printer and author will not be held responsible for any inadvertent error(s). In
case of any dispute, all legal matters are to be settled under Delhi jurisdiction only.
First Edition: 2010
ISBN 978-81-8448-823-4
Typeset at JPBMP typesetting unit
Printed at Ajanta Press
 Dedicated to
The memory of my father
Late (Dr) LN Sengupta
 PREFACE

This book essentially deals with the Problem-based Questions in Pathology and their solutions. As this
is a new field. I am providing a user’s guide!
• Do not get nervous about the size of the book! Problems and solutions (written over white
background) occupy less than 20% of total pages. Rest more than 80% of the book covers related
discussions on Systemic Pathology (written over gray background). You can easily skip those
pages provided your preparation is adequate.
• There are also unavoidable repetitions increasing volume of this book. Some of the chapters like
discussion on soft tissue tumours are not so much important for undergraduates. But these are
important in clinical teaching.
• There are about 239 solved and unsolved problems in this book. All of these are categorized into
four grades as below:
***: Must know and important for examination.
***: Must know but not so important for examination.
**: Better to know.
*: Nice to know.

Certainly, students can choose what to read!

• Do not consider this book as a text of systemic pathology because:
– Pathological changes in different organ systems are not systematically discussed but
described according to the related problems.
– A lot of diseases are not discussed.
– There is no picture.
• Still I sincerely hope that this book will be considered as a helpful reference for study of systemic
pathology because:
– Discussions are presented in point-wise easily comprehensible manner.
– Most of the important diseases are well covered.
– Some topics may prove useful to clinical students and even to PG entrance examinee.
• Solutions to the problems are approached in multiple ways. Students can adopt any one of
them.
• Future suggestions from readers will be gratefully accepted.
• Finally, it is very difficult for a para-clinical student to consider the problems as patients and
not as mere questions. It is my intention to help them to see the affected, behind the problems. I
shall consider myself successful, if at least one of the readers can use his study of problems into
the field of clinical differential diagnosis.

Sanjay Sengupta
 ACKNOWLEDGEMENTS

I express my heartfelt gratitude to:

• My students who by their almost universal poor approach towards solution of the problems,
make me aware about necessity of such type of book.
• Jaypee Brothers, my Publisher, for encouraging me to become author.
• Dr Amit Gupta, Basic teacher, Pathology, BMCH and Dr Biswajit Kundu, Basic teacher,
Pathology, BMCH, for their generous help during initial phases.
• All my colleagues in the Departments of Pathology of CNMCH, MCH, Dr BCRMH for Children
and BMCH for their constant co-operations.
• Mr Rajbibar Majumdar and Mr Sekhar Dey for their kind assistance.
• All members of my family and particularly to 9-year-old Master Ritam Sengupta, who is eagerly
waiting for the completion of his “father’s book”.
 CONTENTS

Chapter 1: Cardiovascular System ...................................................................................................... 1-22

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 for last 7 days. What is your provisional
diagnosis? What are the other possibilities? How do you investigate the case? .............................. 1
— Acute rheumatic fever
— Juvenile idiopathic arthritis
— Septic arthritis
CQ2: A boy aged 15 years 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 back.
H/O sore throat 3 weeks back. What is your provisional diagnosis? How will you confirm
your diagnosis? ............................................................................................................................. 4
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 back. or What is the most likely diagnosis? How will you proceed
for confirmation of diagnosis? ..................................................................................................... 4
CQ4: A boy, aged 16, comes with fever and migratory polyarthritis for 1 wk. He is also complaining
of palpitation, respiratory distress and chest pain. What are the possible causes? How will
you proceed for diagnosis? .......................................................................................................... 4
— Lyme disease
CQ5: 28-year 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. What
are the probable causes? How will you investigate the case? ................................................. 5
— Chronic rheumatic heart disease
— Cardiomyopathy
— Constrictive pericarditis
— Primary pulmonary hypertension
— Rheumatoid heart disease
CQ6: Middle aged man is complaining of gradually increasing respiratory distress, chronic cough,
palpitation, and paedal oedema with occasional haemoptysis for last 3 years. He admits
multiple attacks of polyarthritis during childhood. What is your provisional diagnosis?
How will you confirm it? .............................................................................................................. 8
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: ....................................... 8
— Presence of gradually increasing breathlessness for last 2 years.
— Past history of multiple attacks of febrile polyarthritis during childhood.
— What are the possible causes? How will you proceed for diagnosis?
— Sub-acute bacterial 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 haemoptysis
and slowly progressive breathlessness for years. O/E, muco-cutaneous petechial spots and
subungual haemorrhage seen. What is your provisional diagnosis? What can be other
possibilities? Describe the steps for confirmation of diagnosis. ........................................... 10
xii Problem-based Questions in Pathology

CQ9: A 48-year male complaining of sudden onset severe retrosternal chest pain, diaphoresis
and respiratory distress.O/E, rapid and feeble pulse with cold extremities. What are the
possible causes? How will you pinpoint your diagnosis? .................................................... 10
— Myocardial infarction
— Pulmonary embolism with infarction
— Aortic dissection
— Tension pneumothorax
— Acute bacterial pneumonia
— Acute pancreatitis (brief)
CQ10: A 39-year male smoker with hypertension suddenly develops severe left sided chest pain
with extension to left arm, sweating, respiratory distress and syncopal attack. What are the
possibilities? How will you investigate the case? ................................................................... 18
CQ11: A 65-year-old diabetic male gets admitted into hospital with mild retro-sternal discomfort,
breathlessness, tachycardia and progressively falling blood pressure for 3 hours. What is
the most likely diagnosis? How will you establish your diagnosis? ................................... 18
CQ12: A 56-year-old female, in the postoperative period, suddenly developed severe chest pain,
breathlessness, cough with haemoptysis and pyrexia. What is your provisional diagnosis?
How will you proceed for diagnosis? ....................................................................................... 18
CQ13: A 33-year 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. What is your provisional diagnosis? How will you justify your diagnosis?
— Buerger’s disease .................................................................................................................... 19
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.: Painful, tender blood vessel over temporal region. What is the most likely diagnosis?
How will you investigate the case? ........................................................................................... 19
— Temporal arteritis
CQ15: Young female, aged 25, seeks medical attention with coldness and numbness of fingers,
vertigo and dimness of vision.
O/E: Radial pulse on both upper limbs very weak. What is your diagnosis? How will you
establish your diagnosis? .......................................................................................................... 20
— Takayasu’s arteritis
CQ16: A 30-year female presenting with a small, elevated, firm and tender nodule, reddish in
colour, at the subungual region of left second finger. What is your provisional diagnosis?
How will you confirm your diagnosis? .................................................................................... 21
— Glomus tumour
CQ17: A 36-year 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 lymphadeno-
pathy. What are these lesions? How can you confirm the diagnosis? ................................. 21
— Kaposi’s sarcoma
CQ18: Teen-age 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. What is your provisional diagnosis? What can be other
possibilities? How will you approach for diagnosis? ............................................................ 22
CQ19: A 39-year-female, presented with slowly developing breathlessness, chronic cough and
occasional haemoptysis for last 3 years. Past H/O repeated attacks of joint swelling with fever
 Contents xiii

during childhood. What are the possible causes? Discuss lab. investigations for confirmation
of your diagnosis. ........................................................................................................................ 22
CQ20: A 56-year-male, smoker and hypertensive, complaining of severe pain in the left side of chest
with sweating, palpitation and respiratory distress for 1 hour. What are the probable causes?
Describe the steps for diagnosis. ............................................................................................... 22

Chapter 2: Respiratory System .......................................................................................................... 23-62

RQ1: A 52-year male, smoker comes to outdoor with cold, cough, fever, respiratory distress and
profuse expec-toration for 3 days. Previous history of similar attacks in last 2 years is present.
What are the possible causes? How will you proceed for diagnosis? ................................. 23
— Chronic bronchitis
— Bronchial asthma
— Bronchiectasis
— Lung abscess
— Acute bacterial pneumonia (Detailed)
RQ2: A 68-year male, smoker presented with gradually increasing respiratory distress for last 1
year with cough, scanty expectoration and weight loss. What are the possibilities? How
will your confirm your diagnosis? ............................................................................................ 31
— Emphysema
— Interstitial lung disease
— Pulmonary tuberculosis
RQ3: A 28-year female presented with recurrent episodes of cough, wheezing and respiratory
distress for more than 2 years. What is the possible cause? What can be other possibilities?
How will you proceed for laboratory investigation of the case? ........................................... 41
— Acute left ventricular failure
RQ4: 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. What are the possible causes? How will you investigate the case? .................. 42
RQ5: A male child, aged 5 years, admitted into Paediatric ward with high fever, chest pain,
palpitation, respiratory distress and expectoration of rusty sputum for 2 days. What is your
provisional diagnosis? How will you investigate the case? ................................................. 43
RQ6: A 75-year 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. What is the most possible complication developed in this case? What are other
possibilities? How will you proceed to diagnose the compilation? ..................................... 44
RQ7: Female patient, aged 53 years presented with low-grade fever, chest pain, weight loss and
occasional haemoptysis for last 4 months. What are the possibilities? How will you diagnose
the case? ........................................................................................................................................ 44
— Bronchogenic carcinoma
— Metastatic lung tumour
— Lymphoma of lung
RQ8: A 32-year male seeks medical attention for gradually increasing breathlessness, fever, cough,
and occasional haemoptysis with right-sided pleural effusion. What is the most possible
diagnosis? What can be other possibilities? How can you confirm your diagnosis? ....... 49
xiv Problem-based Questions in Pathology

RQ9: A 60-year-old male smoker is complaining of dry cough, occasional haemoptysis, chest
pain, anorexia, weight loss and clubbing for 5 months. What is your provisional diagnosis?
How will you establish your diagnosis? .................................................................................. 49
RQ10: A 58-year-male smoker working in an asbestos factory for 30 years comes to outdoor with
chest pain, weight loss, chronic cough, occasional haemoptysis 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.
What are the possibilities? How will you progress for confirmation of diagnosis? .......... 49
— Malignant mesothelioma
— Benign mesothelioma
— Asbestosis with pleural effusion
RQ11: Middle aged female is complaining of chronic cough, chest pain and shortness of breath for
more than 1 year.
Chest X-ray: Bilateral hilar lymphadenopathy.
What is your provisional diagnosis? What other possibilities can come into consideration?
How will you confirm your diagnosis? .................................................................................... 53
— Sarcoidosis
RQ12: A 32-year female complains of intermittent attacks of diarrhea, cyanosis and flushing for 4
years along with repeated attacks of bronchoconstriction. She also admits of dry cough and
occasional haemoptysis for same duration. Chest X-ray shows a small-circum-scribed nodule
in the left lung. What is the most possible diagnosis? How will you proceed for confirmation
of your diagnosis? ....................................................................................................................... 56
— Bronchial carcinoid
RQ13: A 45-year-old male presents with a small, smooth rounded mass shadow on routine chest
X-ray. There are no accompanying symptom. What is the most probable diagnosis? How
will you confirm the diagnosis? ................................................................................................ 57
— Lung hamartoma
RQ14: A 50-year-old male, non-smoker, seeks medical attention for cough with expectoration,
often blood tinged, weight loss, anorexia, chest pain and evening rise of temperature for 3
months. What is your provisional diagnosis? What can be other possibilities? Describe the
steps for confirmation? ............................................................................................................... 57
RQ15: Young female, aged 29 years, was admitted to hospital with cough, occasional haemoptysis,
low grade fever and slowly developing breathlessness for more than 1 year. O/E: Bilateral
iritis, parotitis, cervical lymphadenopathy and hepatosplenomegaly. What are the
possibilities? How will you confirm your diagnosis? ............................................................ 57
— Sjögren’s syndrome
RQ16: Female, aged 58 years, seeks medical attention for dry cough, occasional haemoptysis, 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. What is your provisional and differential
diagnosis? Describe steps for confirmation of your diagnosis. ............................................ 59
RQ17: A 72-year-old male, smoker, gets admitted with dry cough, occasional haemoptysis, 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. What is the most likely diagnosis?
What are other possibilities? Describe steps for confirmation of diagnosis. ...................... 59
 Contents xv

RQ18: A 73-year-old male, heavy smoker for more than 30 years, developed chronic cough, haemop-
tysis, 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 hypercalcaemia.
What is your provisional diagnosis? How will you approach for confirmation? ............. 59
RQ19: A 68-year 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. What is the
most likely diagnosis? How can you explain all the features? What are other causes and
how will you proceed for diagnosis? ........................................................................................ 59
—Thymoma
RQ20: A 72-year female, presented with intense chest pain, anorexia, weight loss, cough with
occasional haemoptysis for one month. She also complained of intermittent flushing and
diarrhoeal attacks. O/E: Muscular weakness and peripheral neuropathy of both lower
limbs seen. Serum electrolyte study showed hyponatremia. What is your provisional
diagnosis? What can be other possibilities? How will you confirm you diagnosis? ........ 61
RQ21: A 50-year male, smoker, with weight loss, chest pain, cough and haemoptysis for 3 months;
Chest X-ray: Large SOL at central portion of lt. lung. What is your provisional diagnosis?
How will you confirm your diagnosis? .................................................................................... 61
RQ22: A 27-year female, non-smoker, complaining of chronic cough, night sweat, weakness, slowly
developing breathlessness and cervical lymphadenopathy. What are the possibilities? How
will you investigate the case? .................................................................................................... 61
RQ23: Middle aged man with long-standing diabetes presented with low-grade fever for 2 months
with chronic cough and occasional haemoptysis. What is your provisional diagnosis? What
are other possibilities? Describe steps for diagnosis? ............................................................ 61
RQ24: A 59-year male, working in sand blasting, gradually developed shortness of breath with
chronic cough. 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? ............................... 61
RQ25: A 9-year-old female child presented with sudden onset of fever with chill and rigor, chest
pain, cough and respiratory distress. What is the most likely diagnosis? What should be
your approach for confirmation of diagnosis? ........................................................................ 61

Chapter 3: Gastrointestinal Tract, Hepatobiliary System and Pancreas .................................. 62-149

GQ1: Middle aged alcoholic male admitted into emergency ward with epigastric pain and
haematemesis for 24 hours. He admits frequent attacks of pain particularly during empty
stomach in the recent past.
What is your provisional diagnosis? What can be other possibilities? How will you confirm
your diagnosis? ........................................................................................................................... 62
— Peptic ulcer
— Zollinger-Ellison syndrome
— Gastric carcinoma
— Acute gastric ulcerations
— Bleeding oesophageal varices
— Cirrhosis of liver (brief)
— Oesophageal tear
xvi Problem-based Questions in Pathology

GQ2: Male, aged 36 years comes to emergency with severe epigastric pain and vomiting for 5
hours. What are the possibilities? How will you investigate the case?
— Acute pancreatitis (detailed including pancreatic pseudo-cyst) ..................................... 71
— Acute cholecystitis
— Chronic cholecystitis
GQ3: Middle aged female seeks medical attention for a lump in the epigastric region with anorexia
and vomiting for 3 months. What can be the possibilities? What will be your line of approach
for correct diagnosis? .................................................................................................................. 76
— Metastatic liver tumours
— Hepatocellular carcinoma
— Carcinoma of gall bladder
— Carcinoma of the pancreas
GQ4: A 66-year-old female presenting with anorexia, weight loss and weakness for 6 months.
There is also history of haematemesis. On examination, there is a palpable lump over
epigastric region.
What is your provisional diagnosis? What are other possibilities? How will you investigate
the case? ........................................................................................................................................ 80
GQ5: Old female, aged 63 years, 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 haemoglobin concentration and hyper-segmented
neutrophils with macro-ovalocytes.
What is your provisional diagnosis? How will you confirm your diagnosis? ................... 80
GQ6: A 39-year female presented with fever associated with chill and rigor and tender hepato-
megaly.
What are the causes? How can you confirm your diagnosis? .............................................. 80
— Amoebic liver abscess
— Pyogenic liver abscess
— Ascending cholangitis
GQ7: Female aged 49 years complaining of nausea, anorexia, and pain abdomen for last 6 months.
O/E, there is tenderness with a lump in the right hypochondrial region.
What are the possibilities? How can you confirm your diagnosis? ..................................... 83
GQ8: A 36-year male presenting with anorexia low-grade fever, vomiting, pain abdomen and
yellowish discolouration of urine for 1 month.
What is the most probable diagnosis? What are other possibilities? How will you proceed
for diagnosis? ............................................................................................................................... 84
— Infective hepatitis
— Choledocholithiasis
GQ9: A 63-year-male patient presents with anorexia, weight loss and dysphagia to solid food for
last 2 months. He also admits occasional bouts of haematemesis in recent past.
What is your provisional diagnosis? What can be other possibilities? How will you confirm
your diagnosis? ........................................................................................................................... 91
— Malignant tumours of oesophagus
— Reflux oesophagitis
 Contents xvii

GQ10: A 58-year-old male presents with ascites, pedal oedema, anorexia, weight loss, muscle
wasting of the extremities for last 4 years. He also complains of three attacks of haematemesis
and malena during last one year. What are the possible causes? How can you confirm your
diagnosis? .................................................................................................................................... 94
— Alcoholic liver disease (Fatty liver, Alcoholic hepatitis, Alcoholic cirrhosis)
GQ11: A 32-year 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 coloured stool.
O/E, there is hepatosplenomegaly.
What are the possibilities? How will you investigate the case? ........................................... 98
— Primary biliary cirrhosis
— Secondary biliary cirrhosis
— Primary sclerosing cholangitis
GQ12: A 23-year-male presents with fluctuating hyperbilirubinaemia, predominantly
unconjugated, for years without illness. What is your provisional diagnosis? What may be
other possibilities? How can you confirm your diagnosis? ................................................ 102
— Gilbert’s disease
— Criggler-Najar syndrome
— Dubin-Johnson and Rotor’s syndrome
— Hemolytic jaundice
GQ13: A 22-year-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.
What are the possible causes? How will you confirm your diagnosis? ............................ 104
— Wilson’s disease
— α1 anti-trypsin deficiency (hepatic injury)
— Drug induced hepatitis
— Autoimmune hepatitis
GQ14: A 8-year-old male child admitted into paediatric 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.
What are the possible causes? How will you investigate the case? ................................... 107
— Indian childhood cirrhosis
GQ15: A 53-year female presented with hepatomegaly. Ultrasound shows a single large mass on
right lobe of liver.
What can be the possibilities? How will you investigate the case? ................................... 109
— Hydatid cyst
GQ16: A 41-year-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. What is your provisional diagnosis? What are other possibilities? How will you
confirm the case? ....................................................................................................................... 111
— 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.
What are the possible causes? How can you confirm your diagnosis? ............................. 113
— Coeliac disease
— Tropical sprue
— Whipple disease
xviii Problem-based Questions in Pathology

— Giardia lamblia infection

— Crohn’s disease
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.
What can be the possible causes? Give an outline for confirmation of your diagnosis?
What are the possible causes? How will you investigate the case? ................................... 119
— Malnutrition related malabsorption
— Lactase deficiency
— Abetalipoproteinemia
— Cystic fibrosis
GQ19: GQ19: A 36-year female presents with frequent attacks of diarrhoea, weight loss, fever and
abdominal pain for last 3 years. What are the possible causes? How will you investigate the
case? ............................................................................................................................................ 123
— Ulcerative colitis
— Irritable bowel syndrome
GQ 20: Female aged 33 years is admitted into emergency ward for frequent bouts of bloody diarrhoea
with tenesmus and toxic features. H/o similar attacks twice during last 1 year are reported.
What are the possible causes? How will you confirm your diagnosis? ............................ 129
— Bacillary dysentery
— Ischaemic bowel disease
GQ21: A 58-year 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.
What are the possible causes? How will you investigate the case? ................................... 132
— Colorectal carcinoma
— Carcinoid tumour
— GI tract lymphomas
— Colorectal polyps
— Hookworm infestation
GQ22: A 63-year male presented with alternate attacks of diarrhoea and constipation for 3 months
with an ill defined vague lump in the iliac fossa. What are the possible causes? How will
you confirm your diagnosis? ................................................................................................... 141
— Ileocaecal TB
GQ 23: Teenage girl comes to emergency with acute pain in the right iliac fossa with vomiting and fever for
12 hours. What are the possible causes? How will you proceed for diagnosis? .......................... 143
— Acute appendicitis
— Meckel’s diverticulitis
— Amoebic colitis
— Acute salpingitis
— Ovarian torsion
— Acute cystitis
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. What are the possible
causes? How can you confirm your diagnosis? .................................................................... 147
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GQ25: A 69-year-old male presented with anorexia, wt. loss and pallor for 6 months. On
examination, there was hepatomegaly and a vague, ill-defined mass in the right lower
abdomen
What is your provisional diagnosis? How can you investigate the case?. ....................... 148
GQ26: Male, aged 59 and known alcoholic, complains of gradual swelling of abdomen and paedal
oedema for 2 years. There was a bout of haematemesis 2 months back.
What is your provisional diagnosis? How will you investigate the case? ........................ 148
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.
What is your provisional diagnosis? How can you confirm your diagnosis? ................. 148
GQ28: Teenage girl comes to you with anorexia, nausea, vomiting and fever for 3 days. She also
complains of yellowish discolouration of urine.
What are the possible causes? How will you approach for diagnosis? ............................ 148
GQ29: A 70-year-old male patient presents with anorexia, weight loss, fatigue and upper abdominal
pain for 2 months. O/E, liver is palpable with sharp margin.149
What can be the possible etiologies? What should be your line of investigation? ........... 149
GQ30: A 25 year female gets admitted into emergency ward with bloody dysentery, pain abdomen and
features of shock. What are the possible causes? How will you reach diagnosis? ...................... 149
GQ31: A 56-year male smoker is complaining of acidity and pain upper abdomen for 1 year. He
has one attack of haematemesis.
What are the likely causes? How will you investigate the case? ........................................ 149
GQ32: A 5-year-old girl presents with ascites and paedal oedema for 1 year. O/E, there is
splenomegaly.
Enumerate possible causes. Discuss the investigations you want to perform for confirmation
of diagnosis. ............................................................................................................................... 149

Chapter 4: Genitourinary System .................................................................................................. 150-271

GUQ1: A 40-year-old male presents with weakness, fatigue, polyuria, hypertension and occasional
haematuria for 3 years. O/E, bilateral abdominal lumps at flanks.
What are the possible causes? How will you investigate the case? ................................... 153
— Adult polycystic kidney
— Childhood polycystic kidney disease
— Hydronephrosis
— Renal calculi
GUQ2: Girl aged 6 years comes to outdoor with puffy face, pedal oedema, oliguria and haematuria
for 1 week. O/E, there is hypertension.
What is your provisional diagnosis? What can be other causes? How will you investigate
the case? ...................................................................................................................................... 155
— Acute (post-streptococcal) proliferative glomerulonephritis
— Non-streptococcal proliferative glomerulonephritis
— Rapidly progressive glomerulonephritis
— IgA- nephropathy
GUQ3: Boy of 4 year is brought to you with generalized swelling of the body (anasarca) for 5 days.
Urine examination shows marked proteinuria.
What is your provisional diagnosis? Enumerate the causes and how will you confirm your
diagnosis? .................................................................................................................................. 160
xx Problem-based Questions in Pathology

— Lipoid nephrosis (minimal change glomerulonephritis)

— Membranoproliferative glomerulonephritis
— Membranous glomerulonephritis
— Focal segmental glomerulosclerosis
GUQ4: A 42-year female admitted into hospital with anasarca and hypertension for 2 weeks. Routine
urine examination shows massive proteinuria.
What is your provisional diagnosis? What are the causes of development of this disease?
How will you establish the etiology? ...................................................................................... 165
— Diabetes mellitus
— Amyloidosis
— SLE.
— IgA nephropathy
— Focal segmental glomerulosclerosis
— Lipoid nephrosis
GUQ5: A 33-year 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.
What is the possible diagnosis? How will you investigate the case? ................................ 188
GUQ6: A 29-year-old male presented with anasarca and heavy proteinuria. On enquiry, there was
long standing H/O diabetes mellitus.
What is your diagnosis? How will you confirm your diagnosis? ...................................... 188
GUQ7: A 53-year-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.
What is the possible diagnosis? How will you confirm it? ................................................. 188
GUQ8: A 42-year-female presents with haematuria, proteinuria, hypertension and haemoptysis for
2 wks.
What is your provisional diagnosis? What are other causes? How will you confirm your
diagnosis? .................................................................................................................................. 188
— Wegner’s granulomatosis
— Malignant hypertension
— Renal cell carcinoma
GUQ9: A 15-year-girl complains of acute abdominal pain, knee joint swilling, haematuria and
purpuric rashes over buttock.
What is the provisional diagnosis? What can be other possibilities? How will you confirm
your diagnosis? ......................................................................................................................... 194
— Henoch-Schönlein purpura
GUQ10: 30-year-male is presenting with severe oliguria, hypertension and oedema for last 24 hours.
H/o haematuria for 2 wks; patient was symptomless 2 wks back.
What is your provisional diagnosis? What will be your approach for confirmation of
diagnosis? .................................................................................................................................. 195
— Rapidly progressive glomerulonephritis (RPGN)
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GUQ11: A 63-year-old male presents with slowly progressive weakness, anorexia, fatigue and weight
loss for 1 year. O/E, there is oedema and hypertension.
Inv.: Urine protein ++; Blood urea – 86 mg%; Serum creatinine – 3.2 mg%
What is your provisional diagnosis? What are the most common causes? How will you
differentiate the conditions? .................................................................................................... 196
— Chronic glomerulonephritis
— Chronic pyelonephritis
— Analgesic abuse nephropathy
GUQ12: A 51-year-male admitted to emergency ward with anuria for 24 hours. following an attack
of diarrhoea and vomiting for 3 days. What can be the possibilities? How will you investigate
the case? ...................................................................................................................................... 200
— Acute tubular necrosis
— Haemolytic-uremic syndrome
GUQ13: A 36-year-female presents with fever associated with chill and rigor, malaise vomiting,
dysuria, frequency and pain at right costovertebral angle for 5 days.
What can be the possibilities? How will you investigate the case? ................................... 203
— Acute pyelonephritis
GUQ14: A 28-year-female presenting with fever, accompanied by chill and rigor, vomiting, dysuria,
haematuria and severe pain in the lower abdomen for 24 hours.
What are the possible causes? How will you investigate the case? ................................... 205
— Ureteric calculi
— Lower urinary tract infection
GUQ15: 54/M presented with repeated attacks of haematuria for last 6 months.
What are the possible causes? How will you confirm your diagnosis? ............................ 206
— Renal TB
— CA urinary bladder
GUQ16: A 63-year-male presents with recurrent haematuria for last 3 months with mild left
costovertebralpain. O/E, there is a palpable swelling at left flank.
What is your provisional diagnosis? What can be the differential diagnosis? How can you
investigate the case? .................................................................................................................. 211
GUQ17: A 52-year-male presents with intermittent haematuria for 3 months with attacks of frequency
and dysuria.
What are the possible causes? How will you investigate the case? ................................... 211
— Chronic prostatitis
— Acute prostatitis
— Chronic cystitis
— Acute cystitis
— Hunner’s ulcer
— Cystitis glandularis
— Malakoplakia
GUQ18: A 53-year-male presented with painless haematuria for 4 months along with rapidly
developing left sided varicocele. O/E, there is a lump over left flank.
What is your provisional diagnosis? How will you confirm your diagnosis? ................. 213
xxii Problem-based Questions in Pathology

GUQ19: A 3-year-old male child is brought to Paediatric outdoor with rapidly increasing abdominal
lump for 2 months. Associated symptoms are fever, haematuria and weakness.
What is your provisional diagnosis? What can be other possibilities? How will you investigate
the case? ...................................................................................................................................... 213
— Wilm’s tumour
— Neuroblastoma
— Rhabdomyosarcoma
GUQ20: A 46-year-male comes with an elevated, ulcerated lesion over glans penis, present for 2
months.
What are the possible causes? How can you confirm your diagnosis? ............................. 218
— 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 non-tender, small right-sided inguinal swelling
present since birth. O/E, right scrotal sac is empty.
What is your provisional diagnosis? What are the investigations you want to perform for
confirmation? ............................................................................................................................. 223
— Cryptorchidism
GUQ22: A 16-years-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.
What is your provisional diagnosis? How can you confirm your diagnosis? ................. 224
— Mumps and mumps orchitis
GUQ23: A 56-years-male presents with a cauliflower like growth with central ulceration over glans
penis for 2 months. O/E, the mass is non-tender. There are also two discrete firm lymph
nodes in the left inguinal region. What is your provisional diagnosis? How will you confirm
your diagnosis? ......................................................................................................................... 226
GUQ24: Male aged 63-year-seeks medical attention for urinary frequency, nocturia, dysuria and
sense of incomplete evacuation of bladder for last 6 months.
What is your provisional diagnosis? What can be other possibilities? How will you proceed
for confirmation? ....................................................................................................................... 226
— Nodular hyperplasia of prostate
— Prostatic carcinoma
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.
What is your provisional diagnosis? What can be other possibilities? How will you investi-
gate the case? ............................................................................................................................. 231
GUQ26: A 39 years 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.
What is your provisional diagnosis? How will you confirm your diagnosis? ................. 231
— Testicular tumours
GUQ27: A 63/M presents with left supraclavicular hard lymph node, noted 2 weeks back. O/E,
hard, non-tender left testicular swelling present.
What is your provisional diagnosis? Enumerate different histological variants appropriate
for history. How will you confirm your diagnosis? .............................................................. 236
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GUQ28: A 4-year-male child is brought to OPD with right testicular swelling for 1 month. O/E,
medium sized swelling, nodular and non-tender without pallor or, lymphadenopathy.
What are the possible causes? How will you investigate the case? ................................... 236
GUQ29: A 37-year-male comes to outdoor with right testicular swelling noted 2 weeks back after an
inguinal injury. O/E: Irregular, nodular swelling of right testis with loss of testicular
sensation. What are the possible causes? How will you investigate the case? ................ 236
— Clotted hydrocele
GUQ30: Middle aged female, 42-year-age, comes to G and O OPD with leucorrhoea for 6 months. Pap
smear examination shows presence of dysplastic cells. What are the possible causes? How
will you investigate the case? .................................................................................................. 237
— Chronic cervicitis
— Chronic cervicitis with low grade and high grade cervical intraepithelial lesion
— Invasive carcinoma of cervix
GUQ31: A 45-year-female comes to Gynae OPD with H/O postcoital bleeding.
What is your provisional diagnosis? How will you investigate the case? ........................ 242
GUQ32: A 39-year-multiparous woman is complaining of menorrhagia and irregular vaginal bleeding
for last 6 months. She also complains of dysmenorrhoea. P/V: Bulky uterus
What is your provisional diagnosis? What are other causes? How can you confirm your
diagnosis? .................................................................................................................................. 242
— Leiomyoma of uterus
— Endometrial CA.
— Choriocarcinoma of uterus
GUQ33: A 63-year-female comes to Gynae OPD with postmenopausal vaginal bleeding
What are the possible causes? How will you confirm your diagnosis? ............................ 247
GUQ34: A 35-year female presents with irregular vaginal bleeding for last 3 months.
H/o abortion 5 months back; Inv: Chest X-ray shows multiple SOLs in both lungs.
What is your provisional diagnosis? How can you confirm your diagnosis? ................. 247
GUQ35: A 25-year-female with amenorrhoea for 10 weeks is complaining of excessive vaginal bleeding
and passage of grape like structures.
What is your provisional diagnosis? What can be other possibilities? How can you confirm
your diagnosis? ......................................................................................................................... 247
— Hydatidiform mole
— Invasive mole
— Placental site trophoblastic tumour
GUQ36: 37/ F presents with a large lower abdominal swelling for 3 months.
USG: Large right ovarian SOL 16 cm in diameter partly solid and partly cystic with multiple
deposits in omental tissue. What is your provisional diagnosis? How will you investigate
the case? ...................................................................................................................................... 250
— Ovarian tumour
GUQ37: A 49-year-female presents with ascites for 3 months. USG shows presence of right ovarian SOL, 10
cm in diameter. What are the possible causes? How can you confirm your diagnosis? ............. 258
GUQ38: A 42-year-parous woman is complaining of voice changes and hirsutism for 2 months. P/V
examination shows right ovarian enlargement. What are the possible causes? How can you
confirm your diagnosis? ........................................................................................................... 258
GUQ39: A 10-year-old girl comes to outdoor with rapidly developing lower abdominal mass and
tenderness. P/V examination shows huge enlargement of left ovary.
What are the possible causes? How can you proceed for diagnosis? ................................ 259
xxiv Problem-based Questions in Pathology

GUQ40: A 8-year-old girl comes to outdoor with features of precocious puberty. USG of abdomen
shows a solid ovarian SOL on left ovary – 8 cm in diameter.
What are the possible causes? How can you investigate the case? .................................... 259
GUQ41: A 23-year-old female comes to outdoor with a well-defined mobile lump 2 cm in diameter
over upper and outer quadrant of left breast.
What is your provisional diagnosis? How can you confirm your diagnosis? ................. 259
— Fibroadenoma of breast
— Phyllodes tumour
— Sarcoma of breast
GUQ42: Female, aged 37 years, comes to outdoor with a vague nodular swelling over right breast for
1 year. The mass is tender and tenderness increases during menstruation.
What is your provisional diagnosis? How can you confirm your diagnosis? ................. 261
— Fibroadenosis of breast
— Proliferative breast diseases (Epithelial hyperplasia, Sclerosing adenosis and Small duct
papilloma)
GUQ43: A 58-year female comes to outdoor with hard and fixed lump of left breast 5 cm in diameter
and ulcerations in the overlying skin. She admits presence of a small lump for 9 months
with rapid increase in size during last 3 months. On examination, left axillary lymph nodes
are palpable. What is your provisional diagnosis? How can you classify the disease? What
are the steps for diagnosis? ...................................................................................................... 263
— Carcinoma of the breast
GUQ44: A 34-year-old female comes to outdoor with a lump in the periareolar region of left breast
present for 5 months. What can be the possible diagnosis? How can you confirm your
diagnosis? .................................................................................................................................. 270
— Large duct papilloma of breast
GUQ45: A 41-year-female comes to the outdoor with H /o blood mixed discharge from nipple.
What can be the causes? How will you confirm your diagnosis? ...................................... 271
GUQ46: A 46-year-old male comes to outdoor with painless haematuria and palpable mass on left
flank. What are the possible causes? How will you confirm your diagnosis? ................. 271
GUQ47: A 3-year-old boy presents with a rapidly growing abdominal mass.
What is your provisional diagnosis? What can be other possibilities? How can you confirm
your diagnosis? ......................................................................................................................... 271
GUQ48: A 65-year male presents with lower abdominal pain, dysuria and frequency for more than
3 months. What are the possible causes? How will your investigate the case? ............... 271
GUQ49: A 6-year-old male child gets admitted into Paediatric ward with generalized swelling of
body for 7 days. Routine examination of urine shows heavy proteinuria.
What is your provisional diagnosis? What can be the causes of these changes? How will
you proceed for confirmation of diagnosis? .......................................................................... 271
GUQ50: A 58-year female presents with oedema, hypertension, anaemia and weakness for 6 months.
Blood examination shows serum urea – 72 mg%, serum creatinine – 3.8 mg%.
What are the possible causes? How can you investigate the case? .................................... 271
GUQ51: A 53-year postmenopausal female comes to Gynae OPD with intermittent bleeding P/ V for
3 months. What are the possible causes? How will you establish your diagnosis? ........ 271
GUQ52: A 42-year-old female presents with a painless nodule over upper and outer quadrant of left
breast. Enumerate the causes. How can you pinpoint your diagnosis? ............................ 271
 Contents xxv

Chapter 5: Bone, Joints, Soft Tissue and Skin ............................................................................. 272-343

BQ1: A 70-year female is brought to emergency with # neck femur following minor injury. She
also suffered from # lower end of radius few months back. She admits chronic back pain and
musculoskeletal pain for more than years.
What is the underlying etiology? How will you proceed for confirmation? ..................... 272
— Senile osteoporosis
BQ2: A 16-year-old male comes to outdoor with a discharging sinus just below right knee joint.
O/E, the site shows features of inflammation. The boy is also suffering from pyrexia for 3
weeks.
What are the probable causes? How can you confirm your diagnosis? ............................ 274
— Pyogenic osteomyelitis
— Tuberculous osteomyelitis
BQ3: A 15-year-old boy comes to outdoor with a hard, tender, nodule, 2 cm in diameter, just above
left knee joint, present for 6 months.
X-ray: Cortical lytic shadow in lower part of left femur. What can be the possibilities? How
can you confirm your diagnosis? ............................................................................................ 277
— Osteochondroma
— Osteoid osteoma
— Chondroblastoma
— Chondromyxoid fibroma
— Solitary enchondroma
BQ4: A 19 years female complaining of a rapidly growing tender mass over right shoulder, fixed
to the bone. What is your provisional diagnosis? What are other possibilities? How can you
confirm your diagnosis? ........................................................................................................... 280
— Classification of bone tumours
— Osteosarcoma
— Chondrosarcoma
— Giant cell tumour of bone
— Ewing’s sarcoma
BQ5: A 63-year female comes to OPD with a slowly developing large tumour near hip joint,
present for more than 1 year. What are the possible causes? How will you proceed for
confirmation of diagnosis? ...................................................................................................... 289
— Fibrosarcoma
— Malignant fibrous histiocytoma
— Benign fibrous histiocytoma
— Dermatofibrosarcoma protuberans
— Chordoma
— Metastatic bone tumour
BQ6: A 7-year-old girl presents with a large tender rapidly growing mass, present over mid thigh region
for 3 months. What are the possible tumours? How can you confirm your diagnosis? ............. 295
BQ7: A 29-year female comes to OPD with a globular swelling just below knee joint for more than
one year. What can be the possible causes?How can you confirm your diagnosis? ....... 295
— Synovial sarcoma
— Pigmented villonodular tenosynovitis
— Giant cell tumour of tendon sheath
xxvi Problem-based Questions in Pathology

BQ8: A 22-year-old male comes to Orthopaedic OPD with painful swelling over left shoulder
joint. X-ray shows pathological # with lytic bone lesion.
What are the possible causes? How can you differentiate the conditions? ...................... 299
— Non-ossifying fibroma
— Fibrous cortical defect
— Fibrous dysplasia
— Monostotic variant
— Polyostotic variant
— Solitary bone cyst
— Aneurysmal bone cyst
BQ9: A 59-year-old male presented with localized tenderness and swelling of right upper thigh.
X-ray showed a lytic bone lesion over upper femur with extension into surrounding soft
tissue and pathological fracture.
What are the possibilities? How can you confirm your diagnosis? ................................... 301
BQ10: A 60-year male complaining of weakness, lethargy and diffuse skeletal pain for last 1 year.
O/E, there is anaemia and pedal oedema.
X-ray of the skull shows multiple punched out lytic lesions.
What is your provisional diagnosis? How can you confirm your diagnosis? ................. 302
— Multiple myeloma
— Solitary plasmacytoma
— Monoclonal gammopathy of uncertain origin
— Heavy chain disease
— Primary amyloidosis (brief)
— Waldenstrom’s macroglobulinaemia
BQ11: A 48-year female presenting with painful swelling and deformities of small joints of hands
and feet along with bilateral tender knee joint swelling for last 3 years. What is your
provisional diagnosis? What can be other possibilities? How will you confirm your
diagnosis? .................................................................................................................................. 307
— Rheumatoid arthritis
— Juvenile rheumatoid arthritis
— Gouty, arthritis
BQ12: A 13-year-old girl comes to outdoor with pain and swelling of right knee joint along with
high fever for 5 days. What is your provisional diagnosis? What are other possible causes?
How will you investigate the case? ......................................................................................... 316
— Suppurative arthritis
— TB arthritis
BQ13: A 59-year-old male presents with excruciating pain in the right great toe with swelling and
mild rise of body temperature for 2 days. No H/o local injury.
What is your provisional diagnosis? How can you investigate the case? ........................ 319
BQ14: A 53-year female presents with swelling and tenderness of both small and large joints for
more than 5 years. There is restriction of joint movements with deformities in both hands.
What is your provisional diagnosis? How will you confirm your diagnosis? ................. 319
BQ15: A 30-year male presents with a soft, fluctuant non-tender swelling over right inguinal region for 4
wks. O/ E, there is localized tenderness over lumbo-sacral vertebra with intermittent fever. What is
the possible diagnosis? How can you confirm your diagnosis? ................................................. 319
 Contents xxvii

BQ16: A 37-year-old male presents with a slow growing lump over right wrist joint for 2 years.
What are the possible causes? How can you confirm your diagnosis? ............................. 320
— Ganglion
— Lipoma
— Neurofibroma
— Plexiform neurofibroma
BQ17: A 66-year-old male seeks medical attention with a huge tumour at mid thigh, present for 6
months. X-ray: Soft tissue lump. What are the possible causes? How can you confirm your
diagnosis? .................................................................................................................................. 323
— Liposarcoma
— Malignant peripheral nerve sheath tumours
BQ18: A 23-year male presents with a rapidly growing tumour over nape of the neck for 5 months.
What can be probable causes? How will you establish final diagnosis? .......................... 326
BQ19: A 37-year female seeks medical attention with a large parietal tumour present over ant.
abdominal wall for 6 months. What are the possible causes? How can you differentiate the
causes? ........................................................................................................................................ 326
— Desmoid tumour
BQ20: A Male aged 66-year presents with progressive abdominal swelling for last 3 months.
CT scan of abdomen shows large retro-peritoneal tumour.
What are the possible causes? How can you confirm your diagnosis? ............................. 328
— Leiomyosarcoma
BQ21: A 41-year female comes to skin OPD with a raised, flat black coloured plaque present over
nape of the neck for years. She is complaining of itching and increase in size of the lesion
with colour changes for last 2 months.
What is your provisional diagnosis? Describe the steps for confirmation of diagnosis ............. 330.
— Malignant melanoma
— Pigmented naevus
— Dysplastic naevus
BQ22: A 48-year male complaining of weakness, weight loss and anorexia for last 3 months along
with right inguinal firm swelling; O/E an ulcerated blackish lesion seen over right great toe
present for 1 year along with hepatomegaly.
What is your provisional diagnosis? How can you confirm your diagnosis? ................. 334
BQ23: A 23-year male presents with a soft to firm swelling over back 4 cm in diameter, present for
5 years. What are the possible causes? How can you confirm your diagnosis? .............. 334
— Dermoid cyst
— Sebaceous cyst
BQ24: A 37-year-old male presents with multiple small soft tissue swellings over different parts of
the body for years.
What are the possible lesions? How can you confirm your diagnosis? ............................ 335
BQ25: A 43-year-old male comes to OPD with a slow growing huge tumour covering most of the
scalp and present for more than 5 years.
What is your provisional diagnosis? How will you confirm your diagnosis? ................. 335
BQ26: A 58-year male comes to skin OPD with an elevated ulcerated skin swelling present over
dorsal aspect of forearm for 6 months with irregular infiltrating margin and prominent
blood vessels on superficial surface.
What can be the possible causes? ........................................................................................... 336
— Squamous cell carcinoma of skin
xxviii Problem-based Questions in Pathology

BQ27: A 63-year female presents with a slow growing elevated skin lesion with ulceration present
just below lower eyelid for 2 years.
What is your provisional diagnosis? What can be other possibilities? How can you confirm
your diagnosis? ......................................................................................................................... 337
— Basal cell CA
BQ28: A 39-year female presents with well demarcated plaque like scaly cutaneous lesions over
elbow, knee and scalp for 2 years along with pain and swelling of both knee joints for more
than 6 months.
What is your provisional diagnosis? How can you confirm your diagnosis? ................. 338
— Psoriasis
BQ29: A 39-year female presents with multiple skin bulla, vesicles and ulcerations distributed
widely over trunks and extremities along with mouth ulcerations.
What are the possible causes? How can you investigate the case? .................................... 339
— Pemphigus
— Bullous pemphigoid
— Dermatitis herpetiformis
BQ30: A 7-year-old girl comes to outdoor with a discharging sinus over right ankle joint for 2 wks.
There is accompanying history of high fever with chill. O/E: tenderness over lower part of
tibia.
What is your provisional diagnosis? What can be other causes? How will you confirm your
diagnosis? .................................................................................................................................. 342
BQ31: A 21-year-old male comes to surgery outdoor with a rapidly growing huge tumour present
close to left knee joint for 5 months.
What are the possible causes? How can you establish final diagnosis? ........................... 342
BQ32: A 35-year-old female comes to OPD with a slowly developing globular firm swelling just
below the knee joint for 1 year.
Enumerate possible causes? How can you differentiate the lesions? ................................ 342
BQ33: A 35-year female is complaining of pain and swelling of small joints of both hands for more
than 1 year. She also admits stiffness of all joints particularly during morning for the same
duration.
What is your provisional diagnosis? Describe the criteria for confirmation of diagnosis.
Briefly describe the etiopathogenesis. ..................................................................................... 343
BQ34: A 16-year-old boy presents with a huge swelling near shoulder joint. X-ray shows osteolytic
lesion of upper humerus with soft tissue involvement.
What is your provisional diagnosis? How can you classify the lesion? Now suddenly, the
boy is complaining of breathlessness, chest pain and haemoptysis. What is the possible
complication? How can you confirm the condition? ........................................................... 343
BQ35: A 66-year male comes to outdoor with high fever and tender swelling of left great toe for 2
days.
On X-ray: No # is noted.
What is the most probable diagnosis? Mention the specific haematological investigation
helping in diagnosis. Now the patient is complaining of pain in the right flank with vomiting
and dysuria. Identify the possible complication. How can you confirm it? ..................... 343
 Contents xxix

Chapter 6: Haematology and Lymphoreticular System ............................................................ 344-502

Differential diagnosis of anaemia: .......................................................................................................... 344
— Classification of anaemia
— Diagnosis of microcytic hypochromic anaemia
-Inv. of Fe deficiency anaemia and its causes
-Inv. of thalassaemic syndromes
-Inv. of anaemia of chronic disorder
-Inv. of sideroblastic anaemia
— Diagnosis of macrocytic anaemia
-Causes of macrocytic anaemia
-Inv. of normoblastic macrocytic anaemia
-Inv. of megaloblastic anaemia
•Inv. of Vit B12 deficiency
•Inv. of folate deficiency
— Diagnosis of normochromic normocytic anaemia
-Causes of NN anaemia
-Inv. of aplastic anaemia
(Causes of pancytopenia and ferrokinetic study included)
-Inv. of anaemia of pregnancy
-Inv. of anaemia due to protein energy malnutrition
-Inv. of haemolytic anaemia
-Inv. of anaemia of chronic infection
-Inv. of anaemia of chronic renal failure
-Inv. of anaemia of chronic liver disease
-Inv. of anaemia of chronic inflammatory disorder
-Inv. of anaemia of acute leukaemia
-Inv. of anaemia of chronic leukaemia
-Inv. of anaemia of endocrinopathies
-Inv. of myelopthisic anaemia
— Differential diagnosis of pancytopenia
— D /D of hypersplenism
(Definition, pathogenesis, etiology and diagnosis included)
HQ1: A 39-year-old rural female coming from low socioeconomic background, presents with
progressive weakness, fatigue, lassitude and palpitation for last one year.
O/E, moderate pallor with stomatitis, glossitis and koilonychia; no hepatosplenomegaly
or, lymphadenopathy:
What is your etiological diagnosis? Enumerate possible underlying causes. How can you
confirm your etiological diagnosis and pinpoint underlying causes? .............................. 383
— Fe deficiency anaemia
HQ2: A 4-year-old male child, living in an urban slum, is suffering from irritability, growth
retardation and anorexia for more than 6 months.
O/E: Pallor-+; Liver – Palpable, soft, 1 finger; Spleen – Not palpable; Lymph nodes – 2
discrete small rt. cervical lymph nodes palpable; Hair – Lusterless, dry; Angular stomatitis+
What is your provisional diagnosis about the cause of anaemia? What are the deficient
factors that may lead to development of anaemia? How will you establish the diagnosis of
particular deficiency? ............................................................................................................... 389
xxx Problem-based Questions in Pathology

HQ3: A 55-year-old male is complaining of weakness, anorexia, weight loss and dyspnoea for
last 2 months. He also complains of irregular bowel habit for last 6 months.
O/E, Pallor: +; Liver: Palpable, 3 cm below costal margin with hard nodular tender surface;
Abdominal lump: Palpable over right iliac fossa
What is your provisional diagnosis? What type of anaemia is expected in this set up?
Describe haematological investigations for confirmation of type of anaemia? ................ 389
HQ4: A 31-year-old female gets admitted into medicine ward wih progressively worsening
symptoms like palpitation, chest pain, dyspnoea, weakness and lassitude for last 1 year.
Routine haematological findings are as such: Hb – 6.1 gm%; TRBC – 2.9 million/cumm.;
TLC – 8,200/cumm.; DC – N-59%, E-07%, B-0%, L-33%, M-01%; TPC – 2,16,000/cumm.
RBC series: Microcytic hypochromic anaemia with moderate poikilocytosis and anisocytosis;
no normoblast seen; reticulocyte count low; no parasite seen
What is the possible type of anaemia? Enumerate the causes of development of this type of
anaemia? What are other causes of microcytic hypochromic anaemia? How can you
investigate a case of microcytic hypochromic anaemia? ..................................................... 389
Inv.: Low Hb%, microcytic hypochromic anemia
HQ5: A 43-year-old female patient suffering from weakness, palpitation and easy fatiguability for
last 3 months
O/E: Pallor with tongue ulcers seen; no hepatosplenomegaly or, lymphadenopathy.
Inv: Stool for occult blood test – negative. What can be etiological diagnosis of anaemia in
this set up? How can you investigate the case for confirmation of diagnosis? ................ 390
O/E, pallor, tongue ulcers, hepatosplenomegaly and lymphadenopathy:
— Megaloblastic anaemia
— Pernicious anaemia
— Aplastic anaemia
HQ6: A 53-year-old male comes to outdoor with progressive weakness, anorexia, dyspnoea on
exertion and pallor for last 6 months. He also complains of weakness of lower extremities
with difficulty during walking.
The patient’s record shows H/O gastrectomy 20 years back for bleeding gastric ulcer.
What is your provisional diagnosis? How can you investigate the case? ........................ 399
HQ7: A 37-year-female, suffering from Hashimoto’s thyroiditis, is complaining of gradual loss of
sensation in both legs with progressive difficulty during walking for last 7 months.
O/E, Pallor – Moderate; Icterus–Mild; Hepatosplenomegaly – Mild enlargement
What is your provisional diagnosis? Describe the expected peripheral blood picture in this
case? What is the role of bone marrow aspiration for diagnosis of this case? What other tests
must be done for confirmation? ............................................................................................... 400
HQ8: A 43-year-old male presents with weakness, lassitude, and anorexia for last 6 months.
O/E: Pallor-+; Glossitis -+
Inv: Hb – 8.1 gm %; TRBC -2.8 million / cumm; TWBC-4, 200/cumm; TPC-1, 46,000 /cumm;
DC of leucocytes: N 56%, E03%, B0%, L39%, M02%
Peripheral smear: Macrovalocytosis with presence of hypersegmented neutrophils
What is the possible type of anaemia? What are the causes of this type of anaemia? What
other causes can give rise to macrocytosis of circulating RBC? How can you differentiate
those causes from the anaemia of this particular patient? .................................................. 400
 Contents xxxi

HQ9: A 59-year-old male presents with high fever, severe anaemia and petechial bleeding spots
over trunk and extremities for 3 days. He has received chloramphenicol for treatment of
enteric fever 3 wks back, O/E, no palpable lymph node or, hepatosplenomegaly
What is your provisional diagnosis? Enumerate other causes for development of similar
disorder. How will you confirm your provisional diagnosis? ............................................ 400
HQ10: A 48-year female presents with severe anaemia for 2 months.
O/E, no hepatosplenomegaly or, lymphadenopathy
Inv: Hb – 4.1 gm%, TLC- 2,900/cumm. TPC- 1,42,000/cumm. Dc: N37%, E01%, B00%, L61%,
M01%
RBC series: Normocytic and normochromic
What is your provisional diagnosis? Enumerate other conditions with similar blood picture.
Briefly describe the investigations helping in differential diagnosis. ................................ 401
Inv.: Normochromic normocytic anaemia with pancytopenia:
HQ11: A 4-year-old male child is suffering from growth retardation, irritability and anorexia till
infancy.
O/E, Pallor–Marked; huge enlargement of liver and spleen with sternal tenderness, but no
marked lymphadenopathy; depressed nasal bridge with malar prominence
What is your provisional diagnosis? How can you confirm your diagnosis? ................. 402
— Thalassaemic syndromes
— Beta- thalassaemia major
— Do intermedia
— Do minor
— Alfa-thalassaemia
— Hydrops foetalis
— Hb-H disease
— Alfa-thalassaemia trait
— Silent carrier of alfa-thalassaemia
— Delta-beta thalassaemia
— Hereditary persistence of HbF
— Prevention of thalassaemia
HQ12: A 5-year-old girl has received regular blood transfusions since infancy. Routine blood
examination shows:
Hb – 3.8 gm.%; TRBC – 3.1 million/cumm; TPC – 1,96,000/cumm; DC – N36, E03, B00,
L59,M02 ...................................................................................................................................... 410
RBC series: Microcytic hypochromic anaemia with target cells and polychromasia;
Normoblast: 20/100 WBC
What is your provisional diagnosis? How can you confirm your diagnosis? .......................
HQ 13: A 57-year-male presents with passage of dark, smoky urine for 3 days. He has taken
primaquin 2 days back.
What is your provisional diagnosis? Enumerate other causes giving rise to similar clinical
picture? How can you confirm your diagnosis? ................................................................... 410
— G6PD deficiency haemolytic anaemia
— Favism
— Pyruvate kinase deficiency haemolytic anaemia
xxxii Problem-based Questions in Pathology

HQ14: A 59-year-old female is admitted into emergency ward with anuria for 24 hours. She
complains of snakebite 3 days before.
What is your provisional diagnosis? How can you explain pathogenesis of anuria? Describe
the haematological and biochemical abnormalities expected in this set up. .................... 413
HQ15: A 43-year-old male presents with recurrent episodes of passage of dark, smoky urine for last
one and half years. O/E: Mild pallor with mild hepatomegaly.
What is your provisional diagnosis? What are other possibilities? How can you confirm
your diagnosis? ......................................................................................................................... 413
— Paroxysmal nocturnal haemoglobinuria
— Paroxysmal cold haemoglobinuria
— Cold haemagglutinin disease
HQ16: A 27-year-old male of low socio-economic status comes to medicine outdoor with progressive
weakness, indigestion and abdominal discomfort for last 1 year.
O/E: Moderate pallor without any lymphadenopathy, hepatosplenomegaly or, abdominal
lump
Inv: Stool for occult blood test: Positive
What is the most probable type of anaemia? What is the expected etiology? What can be
other possibilities? How can you confirm your diagnosis? ................................................ 417
HQ 17: A 39-year male alcoholic presents with moderate anaemia. Examination of peripheral smear
shows macrocytic anaemia. What is the possible etiological cause of anaemia? How can
you investigate the case? .......................................................................................................... 417
HQ 18: A 2-year-old male child presents with growth retardation and repeated respiratory tract
infections. O/E: Significant pallor with splenomegaly
Blood picture: Normochromic normocytic anaemia with presence of irreversible sickled
cells
What is the most likely diagnosis? Describe the lab. investigations for confirmation of
diagnosis.
During treatment, the child suddenly develops tender swelling of both hands and feet with
pyrexia.
What is the possible complication? Describe the pathogenesis of development of such
complication. Enumerate other possible complications. ..................................................... 417
— Sickle cell disease
— Sickle cell trait
— Homozygous sickle cell disease
— Double heterozygous sickle cell-beta thal disease
— Other haemoglobinopathies
HQ19: A 19-year-old female is being investigated for moderate anaemia.
O/E: Icterus- Mild; no hepatosplenomegaly
Inv.: Normochromic normocytic anaemia; Sickling test: Positive
What is your provisional diagnosis? What can be other possibilities? How can you confirm
your diagnosis? Enumerate other causes of normocytic normochromic anaemia. .......... 423
HQ20: A 2-year-old female child presents with growth retardation, severe, anaemia, splenomegaly
and mild icterus since infancy.
What are the possible causes? How can you confirm your diagnosis? ............................. 424
 Contents xxxiii

HQ21: A 13-year-old boy presents with chronic anaemia, hepatosplenomegaly and mild icterus.
Result of Hb-electrophoresis: HbF-82%
HbA-15%
HbA2-03%
The boy has not received any blood transfusion.
What is your provisional diagnosis? How can you confirm your diagnosis? ................. 424
HQ22: A 26-year pregnant female presents with moderate anaemia during 2nd trimester of
pregnancy, which is refractory to therapy. Result of Hb electrophoresis:
HbA-93%
HbF-1.5%
HbA2-5.5%
What is your provisional diagnosis? Describe the abnormalities in peripheral smear examina-
tion and relevant biochemical investigations helping in diagnosis? What precaution must
be taken during management of this type of anaemia? What will be your judgment regarding
continuation of pregnancy? ..................................................................................................... 424
HQ 23: A 28-year-old male presents with moderate pallor, mild icterus and hepatosplenomegaly.
Hb-electrophoresis: HbA-48%, HbH-31%, HbF-20%, HbA2-1%
What is your provisional diagnosis? Describe the possible genetic abnormalities in this
case? What are the causes of development of anaemia in this case? Briefly outline lab.
investigations for confirmation of diagnosis. ........................................................................ 424
HQ24: A 16-year-old boy is admitted into medicine ward with irregular pyrexia for more that 3
months.
O/E: Pallor- Moderate; Spleen-Moderately enlarged, firm; Liver- Mild enlargement, firm
What are the possible causes? How can you confirm your diagnosis? ............................. 426
— Chronic malaria
— Chronic Kala-azar
HQ 25: A 4-year-old girl presents with huge splenomegaly and pallor.
What are the possible causes? How can you confirm your diagnosis? ............................. 428
— Gaucher’s disease
HQ26: A 57-year-old male complaining of progressive weakness, weight loss and anorexia for last
3 months. O/E, moderate pallor with massive enlargement of spleen. What are the proba-
bilities? How can you confirm your diagnosis? .................................................................... 430
— CML
— Myelofibrosis with myeloid metaplasia
— Acute myelofibrosis
— Hairy cell leukaemia
HQ27: A 56-year healthy female is complaining of recurrent development of small, localized bruises
at different parts of the body for more than a year.
Inv: B T, C T- Normal; TPC: 2,36,000/cumm
What are the possible causes? How can you confirm your diagnosis? ............................. 438
— Purpura simplex
— Senile purpura
HQ28: A 22-year male comes to emergency with epistaxis. He has similar attacks before. O/E,
small raised telangiectatic spots are seen over oral mucosa. Family history reveals bleeding
manifestations in older brother. What is your provisional diagnosis? How will you confirm
your diagnosis? ......................................................................................................................... 438
— Osler-Rendu-Weber syndrome
xxxiv Problem-based Questions in Pathology

HQ29: A 7-year-old boy is admitted into Medicine ward with colicky pain abdomen, vomiting and
bloody diarrhoea for 2 days. O/E: Bilateral tender knee swelling with large purpuric rashes
over buttocks and both elbow
Investigation: Urine examination shows haematuria and proteinuria.
What is your provisional diagnosis? How can you confirm your diagnosis? ................. 439
Inv.: Urine R.E.: R. B. C. - +, Protein- +:
— Henoch- Schonlein purpura
HQ30: A 4-year-old girl is brought to emergency with severe epistaxis for one day. O/E there are
presence of multiple petechial spots over trunks and extremities without any hepatospleno-
megaly or, lymphadenopathy. History reveals an attack of common cold 2 wks before.
What is your provisional diagnosis? How can you confirm your diagnosis? ................. 441
— Idiopathic thrombocytopenic purpura
HQ31: A 29-year-old female seeks medical attention with repeated attacks of petechial bleeding
spots over trunks and extremities and menorrhagia during last 3 years.
What is your provisional diagnosis? How can you confirm your diagnosis? ................. 444
HQ32: A 12-year-old boy presents with epistaxis and petechial spots over trunks and extremities
for 2 days.
What are the possible causes? How can you confirm your diagnosis? ............................. 444
— Drug induced thrombocytopenia
— Acute leukaemia (ALL or, AML)
HQ33: A 46-year male seeks medical attention with weakness, fever and multiple petechial spots
over body for 3 days. O/E, moderate pallor is present.
What can be the possible causes? How can you confirm your diagnosis? ....................... 453
HQ34: A 27-year-old male gets admitted into emergency ward with excessive bleeding following tooth
extraction. Inv.: Normal platelet count; prolonged bleeding time and clotting time
What is your provisional diagnosis? What can be other causes? How can you confirm your
diagnosis? .................................................................................................................................. 453
— von-Willebrand’s disease
— Thrombasthenia
HQ35: A 7-year-old male child presents with high fever and tender swelling of left knee joint. On
careful enquiry, following facts are revealed:
• Presence of bleeding tendency in one of the maternal uncles of the child
• Bleeding tendency from minor trauma since infancy.
Aspiration from the affected joint yields frank blood.
What is your provisional diagnosis? How can you confirm your diagnosis?
Aspiration from the affected joint yields frank blood. .......................................................... 456
— Haemophilia A and B
HQ36: A 36-year female suffering from obstructive jaundice due to choledocholithiasis for more
than 2 months, has developed easy bruisability following minor trauma.
What is your provisional diagnosis? Explain the pathogenesis of bleeding manifestations.
Mention the investigations necessary for confirmation of diagnosis. ................................ 458
— Haemorrhagic disorder due to Vit. K-dependant factor deficiency
HQ37: A 28-year female, during postoperative period after partial thoracotomy of left lung, suddenly
develops bleeding from multiple sites, fluctuating consciousness and rapid fall of urinary
output.
What is the most likely diagnosis? How can you confirm your diagnosis? ..................... 459
— Disseminated intra-vascular coagulation (DIC)
 Contents xxxv

HQ38: A 26-year female presents with easy bruisability and mild menorrhagia for years.
What are the possible causes? How can you confirm your diagnosis? ............................. 463
HQ39: A 32-year male presents with easy bruisability and prolonged bleeding from minor injuries
since adolescence.
What are the probable causes? How can you confirm your diagnosis? ............................ 463
HQ40: A 56-year male presents with weakness, lassitude and chronic anaemia for more than 3
years. He has received multiple blood transfusions during this period. RBC morphology:
Dimorphic picture with both microcytic hypochromic and normochromic normocytic
erythrocytes.
What is the most possible diagnosis? How can you confirm your diagnosis? ................ 463
— Sideroblastic anaemia
HQ41: A 6-year-old boy presents with high fever, mouth ulcerations, petechial bleeding spots over
skin, severe pallor and sternal tenderness.
What is your provisional diagnosis? How can you confirm your diagnosis? ................. 465
HQ42: A 3-year-old girl is admitted into hospital with high fever, pallor, generalized lymphadeno-
pathy and gum bleeding for 3 days. What is your provisional diagnosis? How can you
confirm your diagnosis? ........................................................................................................... 465
HQ43: A 48-year female, suffering from invasive duct carcinoma of right breast for more than 2
years, gradually develops profound anaemia during last 3 months. Examination of
peripheral smear shows leucoerythroblastic blood picture.
What is the possible cause of progressive anaemia? What is leucoerythroblastic blood picture?
Enumerate the conditions along with differential diagnosis of diseases presenting with
leucoerythroblastic blood picture.
Inv.: PBS shows presence of normoblasts and myelocytes with metamyelocytes: ........... 465
— Leuco-erythroblastic blood picture
HQ44: A 11-year-old girl presents with fever, hepatosplenomegaly and generalized lymphadeno-
pathy for 7 days.
What are the possible causes? How can you confirm your diagnosis? ............................. 466
— Infectious mononucleosis
— Lymphoma
HQ45: A 12-year-old boy presents with pallor and cervical lymphadenopathy. Routine chest X-ray
shows a large mediastinal mass.
What are the possibilities? How can you confirm your diagnosis? ................................... 480
HQ46: A 10-year girl presents with high fever and cervical lymhadenopathy for 7days. There is no
history of ingestion of any drug recently. Blood examination shows:
Hb-4.2 gm%, TLC-3, 600/cumm and TPC-87, 000/cumm.What is the most likely diagnosis
in this set up? How can you confirm your diagnosis? ......................................................... 480
HQ47: A 9-month-old baby is suffering from high fever with respiratory distress for 3 days. Blood
examinations show:
Hb—8.8gm%; Normochromic normocytic anaemia
TLC—48, 500/cumm
DC—Myelocyte: 04%; Metamyelocyte: 07%;
Band form: 15%; Neutrophil: 56%;
Eosinophil: 01%;
Basophil: 00%; Lymphocyte: 17%;
Monocyte: 00%
xxxvi Problem-based Questions in Pathology

TPC – 4,28,000 /cumm

ESR – 118 mn (Ist hour).
What is your provisional diagnosis? How can you explain the blood picture? What other
tests you should perform for confirmation? .......................................................................... 480
HQ48: A 23-year male presents with high fever, severe pallor, hepatosplenomegaly and petechial
bleeding spots over trunk for 3 days.
What is your provisional diagnosis? How can you confirm your diagnosis? ................. 481
HQ49: A 42-year male presents with bleeding gum for 5 days. O/E: Pallor, splenomegaly and
gingival hyperplasia; examination of peripheral smear shows presence of blast cells.
What is your provisional diagnosis? Can you guess about specific subvariant of the disease?
How can you confirm your diagnosis? .................................................................................. 481
HQ50: 46/M presents with chest pain, cold, cough, respiratory distress and high fever for 3 days.
Inv.: Hb – 10.1 gm%, normocytic, normochromic erythrocytes
TWBC – 35,000/cumm
DC: Mye. – 02%, Metamye. – 03%, Band form – 15%, N – 71%, E – 02%, B –00%, L – 06%,
M – 01%
TPC – 3,46,000/cumm
What is your provisional diagnosis? What can be other causes producing similar blood picture?
How can you differentiate these conditions on haematological examinations? ......................... 481
—D /D of myeloid leukaemoid reaction and C.M.L.
HQ51: A 51-year-old female came to outdoor with weakness, pallor and splenomegaly for 2years.
Routine haematological investigation showed: Hb-9.9 gm%, TLC-1, 86,000/cumm, TPC-1,
72,000 / cumm. What is your provisional diagnosis? After 3 months, the lady again came
back with rapid enlargement of spleen, extreme lassitude, progressive pallor and cervical
lymphadenopathy.
What is your provisional diagnosis? What is the possible complication? Mention the clinical
and haematological parameters for diagnosis of this complication. What is the prognosis of
this complication? ..................................................................................................................... 482
Inv.: T.L.C. –Very high
— Accelerated phase of C. M. L.
HQ52: A 66-year-old male presents with cervical and axillary lymphadenopathy for 6 months.
Inv.: TLC-2, 67,000/cumm of which 90% are lymphocytes.
What is your provisional diagnosis? How can you confirm your diagnosis? ................. 483
Inv.: Very high T.L.C. and absolute lymphocytosis:
HQ53: A 47-year-female comes to outdoor with purpuric skin rashes for 3 days with extreme
prostration for last 1 month. O/E, severe pallor with moderate splenomegaly. There is no
past H/o bleeding.
What are the possible causes? How can you confirm your diagnosis? ............................. 483
HQ54: A 43/M presents with weakness, lassitude, moderate pallor, sternal tenderness and
splenomegaly for 6 months.
What are the possible causes? How can you confirm your diagnosis? ............................. 486
HQ55: A 11-year-old boy comes to outdoor with weakness, pallor, fever and cervical lymphadeno-
pathy for 1wk. Chest X-ray: Enlarged mediastinal mass
What is your provisional diagnosis? How can you confirm your diagnosis? ................. 486
HQ56: A 76/M complaining of weakness and generalized lymphadenopathy for more than 6
months.
What are the possible causes? How can you confirm your diagnosis? ............................. 486
 Contents xxxvii

HQ57: A 7-year-old girl is admitted into hospital with high fever, hepatosplenomegaly, generalized
lymphadenopathy and pallor for 5 days. Peripheral smear examination shows presence of
abnormal lymphocytes.
What are the possible causes? How can you confirm your diagnosis? ............................. 486
HQ58: A 29-year-old male comes to outdoor with weakness, weight loss and chronic diarrhoea for
more than 3 months. O/E, patient is chachectic with high fever and having cervical
lymphadenopathy. Careful examination and history taking reveals: H/o intravenous drug
abuse for more than 2 years
What is your provisional diagnosis? What can be other possibilities? How can you confirm
your diagnosis? ......................................................................................................................... 486
HQ59: A 35-Year-old male presents with generalized lymphadenopathy, low grade fever, weight
loss and cough with haemoptysis for last 4 months. Careful history reveals bisexual habits
for 20 years.
What are the possible causes? How can you confirm your diagnosis? ............................. 500
HQ60: A 3-year-old boy presents with severe anaemia, hepatosplenomegaly and growth retardation
since infancy.
What is the most likely diagnosis? What can be other possibilities? Briefly describe the
laboratory investigations for confirmation of your diagnosis? ........................................... 501
HQ61: A 5-year-old boy presents with multiple petechial spots over skin and mucosa 7 days after
an attack of febrile illness.
Mention your provisional diagnosis? What can be other common causes with similar presen-
tation? Describe the peripheral smear and bone marrow findings expected in this set up
along with the role of these investigations in differential diagnosis. ................................ 501
HQ62: A 67-year-old male patient seeks medical attention with severe pallor, hepatomegaly and
right lower abdominal hard mass. He is also complaining of weakness, anorexia and altered
bowel habit for last 3 months.
What is your diagnosis? What is the likely cause of anaemia in this case? Describe the
expected peripheral smear findings in this set up. Mention the biochemical tests essential
for etiological diagnosis of anemia. ........................................................................................ 501
HQ63: A 28-year multiparous woman is complaining of weakness, anorexia, and easy fatiguability
for last 1 year. O/E, moderate degree of pallor with concavity of finger nails
What is your diagnosis about etiology of anaemia? How can you confirm your diagnosis?
What other deficiencies may take part in pathogenesis of anemia in this case? How can you
prove this deficiency by laboratory investigations? ............................................................. 501
HQ64: A 33-year female presents with repeated attacks of spontaneous bleeding in the skin and
mucosa for last 4 years. O/E, no hepatosplenomegaly or, sternal tenderness
What is your provisional diagnosis? How can you confirm your diagnosis? ................. 501
HQ65: A 6-year-old girl is admitted into emergency ward with severe pallor, lymphadenopathy,
and petechial bleeding spots over skin with high fever.
What is the likely diagnosis? What can be other possibilities? Briefly describe the steps for
confirmation of your diagnosis? ............................................................................................. 501
HQ66: A 58-year male is complaining of weakness, lassitude, anorexia, and weight loss for last 3
months. O/E, moderate pallor with huge splenomegaly
What are the common causes? How will you proceed for diagnosis? ............................... 501
HQ67: A 52-year male, with a long history of alcohol addiction, is complaining of weakness, anorexia
and easy fatigability for 6 months. .......................................................................................... 501
xxxviii Problem-based Questions in Pathology

O/E: Severe pallor with angular stomatitis; Hepatosplenomegaly – Mild;

Sternal tenderness – Absent
Mention the likely cause of anaemia? How can you confirm the etiology? ....................... 501
HQ68: A Female aged 38-year gets admitted into medicine ward with severe pallor, confusion and
gait abnormalities. She has undergone gastrectomy 15 years back for uncontrollable peptic
ulcer bleeding.
What is your provisional diagnosis? How can you confirm your diagnosis?
What precautions you must take during treatment of this patient? ................................... 502
HQ69: A 35-year-old male seeks medical attention with high fever, pallor, spontaneous bleeding in
skin and mucosa and sternal tenderness for last 7 days.
What is your provisional diagnosis? What can be other possible causes? How can you
investigate the case? .................................................................................................................. 502
HQ70: A 45-year-old male, treated with chloramphenicol for enteric fever 3 wks back, comes to
outdoor with severe pallor, sternal tenderness, nasal bleeding and high fever.
What is your provisional diagnosis? Describe the expected peripheral blood picture in this
case. What other causes can give rise to similar peripheral smear findings? How can you
differentiate those cases on bone marrow examination? ..................................................... 502
HQ71: A 6-year-old girl presents with pallor, mild jaundice, moderate splenomegaly and repeated
attacks of painful swelling of both hands since infancy. What is your provisional diagnosis?
How will you proceed for confirmation of diagnosis? ......................................................... 502
HQ72: A 19-year-old male presenting with fever and generalized lymphadenopathy for 7 days:
What can be the possible causes? How can you confirm your diagnosis? ....................... 502
HQ73: A 16-year-old boy is admitted into medicine ward with low-grade irregular fever, pallor and
hepatosplenomegaly for more than 6 months.
What are the possible causes? How can you confirm your diagnosis? ............................. 502
HQ74: A 53-year female presents with pallor, fatigue, weight loss and massive splenomegaly for 6
months.
What are the possible causes? How can you confirm your diagnosis? ............................. 502
HQ75: A 32-year female seeks medical attention with continuous fever, diarrhoea and weight loss
for 4 wks. O/E, generalized lymphadenopathy of cervical, axillary and inguinal region;
careful interrogation uncovers that the patient is working as prostitute for more than 15
years.
What is your provisional diagnosis? How can you confirm your diagnosis? How can you
monitor the progress of the disease? ....................................................................................... 502

References ..................................................................................................................................... 503

Index ............................................................................................................................................ 505
 INTRODUCTION

Problem-based questions (PBQs) create problems both for students as well as for teachers. Students
are anxious about their approach for solutions. A teacher’s worry, on the other hand, is when and
how to discuss the problems. This is particularly disturbing during pre or para clinical teaching.
Basic aim of PBQs is to nurture thought process of students. They will be encouraged to think,
analyze and correlate. This will improve their clinical acumen.
Here I try to establish a stepwise analytical method for approaching the problems. As pathological
aspects of diseases are discussed in tandem with problem solution, teachers may find a way of
approaching PBQs during class hours. As for students I hope that they will find enough cases to
exercise logical skill.
Most of the discussed problems are simple and straightforward. This primary type of problem
does not include numerous data and usually points towards an unambiguous familiar diagnosis.
Students must have to identify the possible provisional or, differential diagnosis; rest is easy. Still
now these primary problems are to be encountered during examinations.
More complicated problems containing various information, some of which are irrelevant and
even misleading, are discussed only rarely. Fortunately, these problems are also not expected to be
faced during examination. But we include discussions on some relatively rare diseases, which may
help the students during clinical training. For examination, these portions can be easily skipped.
The book deals with ailments of most of the major systems of human body. Hope you will find
materials of interest there.
Do not forget to read the Preface before dealing with the problems.