Tuesday, January 20, 2015

Long Case with Dr. Kuan

Patient 1

15-year-old Malay teenager presented with 2 days history of high-grade fever, facial puffiness and bilateral leg swelling. She also complained of frothy urine and oliguria. She had history of skin infection (impetigo) a month ago. No history of orthopnea or PND. No history of abdominal pain, jaundice or tea-coloured urine.

Physical examination revealed a obese girl (BMI 40) with no SLE features, CBD attached with smoky and frothy urine. She was not pale or jaundiced. There was no facial puffines or bilateral leg swelling. BP 130/70, HR 90, RR 20. Abdomen looked full. No hepatosplenomegaly. Kidneys were ballotable. Shifting dullness negative. Respiratory and cardiovascular examination were normal.

1. What else do you want to check in patients with metabolic syndrome?

  • Check BP
  • Xanthelasma on face
  • Acanthosis nigricans at axilla, neck, back
  • Sensation of lower limbs, glove and stocking distribution
  • Non-healing ulcer, gangrene
  • Shiny, atrophic changes of legs and feet
  • Fungal infection in between toes

2. Provisional diagnosis?
Post-streptococcal acute glomerulonephritis 

3. Differential diagnoses?

  • Nephrotic syndrome
  • Mixed nephrotic and nephritic
  • UTI (pyelonephritis)
  • Acute on chronic renal failure
  • Lupus nephritis

4. Investigations?

  • Blood - FBC, UFEME, RP, 24h urinary protein, Urine C&S, Serum Ca/Mg/Phos, PT/APTT, Lipid profile, LFT, ESR, VBG, ASOT, C3/C4, ANA/anti-dsDNA, Rh factor
  • Imaging - KUB ultrasound, CXR, Renal biopsy if indicated

5. What parameters do we have in UFEME?
pH, specific gravity, colour, leukocyte, erythrocyte, nitrite, glucose, ketone, protein, bilirubin, urobilinogen   

6. Differentials for bilateral renal enlargement?

  • Hydronephrosis
  • Obstructive uropathy
  • Polycystic kidney disease
  • Diabetic nephropathy
  • Acromegaly
  • Amyloidosis
  • Renal cell carcinoma

7. What can you see in KUB ultrasound?

  • Kidney size
  • Renal parenchyma, increase echogenicity in CKD
  • Look for stones
  • Pelvicalyceal system dilated in CKD
  • Thinning of cortex in CKD
  • Dilated ureter
  • Bladder - look for stone, tumour, lesion, thickened wall etc.

8. Corrected calcium formula?
[0.8 x (40 - albumin in g/L)] + calcium in mmol/L 

9. Anion gap formula? (difference between plasma cations and anions)
Na + K - Cl - HCO3
Normal range : 10 - 18 mmol/L

10. Cockroft-Gault equation? taken from this website

11. Serum osmolarity formula?
2(Na + K) + urea + glucose
Normal range : 280 - 300 mmol/L

12. Management for this patient?

  • Pharmacological - Antibiotic (Amoxicillin or Macrolides), ACE-i to reduce proteinuria, diuretic like Frusemide, no need to start steroid yet in view of positive blood culture in this patient
  • Non-pharmacological - Admit patient, monitor VS, weight and urine output, restriction of fluid, refer nephrologist, manage risk factors like DM, obesity, HPT, DVT prophylaxis, prevention of bed sore, patient education

Patient 2

54-year-old Orang Asli, an ex-smoker (1 pack per day, for 15 years) with underlying COPD, presented with 2 days history of worsening dyspnea associated with low-grade fever, productive cough and wheezing. The symptoms were partially relieved by inhaler. On the day of admission, he was unable to walk or talk in full sentence.

He is on MDI Berodual and MDI Budesonide. He had multiple admissions to hospital for similar complaints, 2-3 times for the past 3 years. His last admission was in December 2014. He had never been in ICU or intubated before. No surgical intervention done.

Physical examination revealed a man in respiratory distress, on nasal prong 3L/min with intravenous hydration, sputum pot with whitish sputum noted on table. He was using accessory muscles to breathe. He was febrile 37.5 'C, RR 20, HR 100, BP 100/70. There was clubbing noted on both hands, no BCG scar on left arm. JVP was not raised. He had barrel chest, increase in AP diameter. Trachea was centrally located. Lungs were hyperresonant on percussion. Air entry equal. Generalised rhonchi was heard bilaterally.

1. Occupational lung diseases?

  • Coal - pneumoconiosis
  • Sand - silicosis
  • Shipyard/plumbing/wiring/roofing/mechanic - asbestosis => mesothelioma

2. Provisional diagnosis?

3. Differential diagnoses?

  • Bronchiectasis
  • Pneumothorax
  • Pulmonary tuberculosis
  • Lung carcinoma

4. Causes of upper and lower lobe lung fibrosis? (taken from this website)

5. Can we give 100% oxygen in COPD patients?
In patients with Type 2 respiratory failure, we cannot give 100% oxygen because they have chronic carbon dioxide retention. They are used to that condition, so we must maintain that hypoxic drive. We must aim for PaO2 60 mmHg (8 kPa) or SpO2 90% okay!  

6. Investigations?
CXR, ABG, FBC, Sputum C&S, CRP, throat swab, RP, ECG, RPG, LFT, Lipid profile, high resolution CT to look at lung parenchyma

7. ECG findings in pulmonary hypertension?

  • Peaked P wave (P pulmonale)
  • Tall R wave
  • Right axis deviation
  • Left ventricle hypertrophy

8. Management for this patient?
Acute - Resuscitation, monitor vital signs, give SABA or SAMA or Combivent, or if not relieved give oral prednisolone or IV aminophylline, can give symptomatic treatment for cough and fever, give mucolytic and antipyrexic. Monitor SpO2, hydrate patient, DVT prophylaxis, close monitoring, aggressive chest physiotherapy, respiratory rehab, vaccination, nutrition, refer dietician.

9. Common organism that can cause bronchiectasis is Pseudomonas. Which antibiotics can cover for Pseudomonas?

  • Cephalosporin - Cefobid, Ceftazidime (3rd), Cefepime (4th)
  • Aminoglycoside - Tobramycin, Gentamicin
  • Carbapenem - Imipenem, Meropenem
  • Quinolone - Ciprofloxacin (2nd), Levofloxacin (3rd), Moxifloxacin (4th)
  • Tazocin (Tazobactam + Piperacillin)

10. Prolonged use of macrolides (eg. Erythromycin) can improve exacerbation of bronchiectasis. How?
By reducing biofilm on lung surface, so there is no opportunity for bacteria to grow there. But be careful with macrolides, they can cause hearing loss!

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