Monday, January 26, 2015

Long Case with Dr. Nik Fatnoon

Patient 1

A 23-year-old female presented with worsening shortness of breath for two days duration and progressive bilateral leg swelling for one day duration. She has Type 2 Diabetes Mellitus, hypertension and chronic kidney disease. No evidence of liver or heart failure.

Physical examination revealed a morbidly obese patient, pale but not jaundiced. Edema was noted up to mid thigh bilaterally. Patient afebrile, BP 138/84, HR 84, RR 14, SpO2 96 under room air. Urine dipstick was not done. All systemic examinations were normal.

1. Provisional diagnosis?
Fluid overload secondary to chronic kidney disease

2. Investigations?
ABG first, because patient might die of respiratory fatigue. Then do ECG to look for acute coronary event, rule out heart failure. If ECG has acute changes and ABG has acidosis, then you cannot dialyse patient! Third, do RP to look at increase level of urea and creatinine. Others: CXR, FBC, 24h urinary protein, LFT.

3. Management?
Since this patient presented with SOB, resuscitate first. Based on ABG and SpO2 result, give oxygen. Monitor and adjust accordingly. 

For leg swelling, give oral or IV Frusemide. Insert branula. Dose depends on response. Monitor urine output. If patient's condition does not improve, consider peritoneal dialysis. Put patient on restriction of fluid, depends on this patient's previous ROF.

Manage the cause of fluid overload. Does the patient has sepsis? Any drugs given? Patient non-compliant? Manage precipitating factors. 

Manage complications of worsening renal failure like uremia, uremic encephalopathy or sepsis. Manage risk factors: DM and HPT.

Patient 2

58-year-old female presented with jaundice and tea-coloured urine for three weeks duration. She had history of taking herbal medications one month prior to the symptoms. She had history of left breast carcinoma 10 years ago, mastectomy done and 6 cycles of chemotherapy completed in HTAA.

Physical examination revealed a thin build female who looked lethargic and dehydrated. She was on IV hydration and urinary catheter. She had generalised jaundice of body and eyes. Patient afebrile, BP 130/90. 

On abdomen examination, tenderness noted at epigastric area. Liver was palpable 3cm below costal margin. Shifting dullness was positive. No stigmata of chronic liver diseases or metastasis. Breast examination revealed 6cm scar at left breast from mastectomy. Right breast was normal. Other systemic examination was normal.

1. Provisional diagnosis?
Hepatitis secondary to taking herbal medications

2. Investigations?
LFT, PT/APTT, Hep B/C viral screening, FBC, RP, US HBS, LDH.

3. Management?
No need to resuscitate because she was well! The jaundice was caused by herbal medications, so stop the medications and monitor patient. Anticipate all the complications of jaundice like hepatic encephalopathy, acute bleeding secondary to coagulopathy, acute renal failure secondary to hepatorenal syndrome and hypoglycemia.

Taken from this website

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