Friday, January 16, 2015

Long Case with Dr. Yousof

Patient 1

Miss C, a 22-year-old Chinese female with underlying SLE, diagnosed 5 years ago was electively admitted for renal biopsy due to persistent cloudy and frothy urine. Her last relapse was 7 months ago, where she presented with fever, facial puffiness, periorbital edema and leg swelling. She had amenorrhea since 3 months ago.

On examination, patient was alert and comfortable. She was on urine catheter, with cloudy and frothy urine. She had moon face, facial puffiness, small multiple macular rash on cheeks as well as multiple purplish striae noted on both lower limbs. Vital signs normal. No significant findings on system examinations.

1. Investigations?
Urinalysis, FBC, RP, LFT, Ca/Mg/Phos, PT/APTT, ESR/CRP, ANA/anti-dsDNA, C3 C4, CXR to look for cardiomegaly or pleural effusion.

2. Management?

  • General - Admit patient to medical ward, Nephrotic chart, Strict I/O chart, Measure urine albumin, Measure weight
  • Pharmacology - Review old medications, Refer nephrologist, ACE-inhibitor
  • Non-pharmacology - Patient education on compliance to medication, wear sunscreen or hat when going out, avoid direct sunlight

3. SLICC criteria to diagnose SLE?

2012 SLICC Criteria
Taken from this website

Patient 2

Mr. R, a 26-year-old Malay man, diagnosed as epilepsy 13 years ago, presented with multiple seizure episodes for one day duration. The first seizure started at night when he was sleeping, 10 minutes duration, generalised tonic clonic seizure with uprolling of eyes and drooling of saliva. There was no urinary or bowel incontinence. Post-ictal, he had severe headache, drowsy, lethargy and retrograde amnesia. Second attack happened 15 minutes later with similar presentation. Post-ictal, he vomited out water and food particles. He had 4 more attacks after that, 15 minutes gap between each other, duration of 3-6 minutes, increasing in severity. After the sixth attack, he had loss of consciousness and was brought to the hospital. He suffered left lip swelling and gum bleeding.

Prior to attack, her mother noticed him being easily lethargic, had low mood and less talkative than usual. No history of drug intake, no trauma, no fever, neck stiffness, no weakness or numbness, no hypoglycemic symptoms reported.

He was diagnosed as epilepsy at age 13, first presentation generalised tonic clonic seizure. He is on T. Carbamazepine and T.Keppra (Levetiracetam). He is on regular follow-up at MOPD. He had attack every 2-3 months. No significant family or developmental history, no childhood trauma or infection. He is a smoker for 13 years, 5-6 sticks per day.

No significant findings on physical examination.

1. Spot diagnosis?
Status epilepticus!

2. Definition of status epilepticus?
Seizures lasting for more than 30 minutes OR repeated seizures without intervening consciousness.  

3. Common causes?

  • Non-compliance to medication
  • Infection
  • Metabolic imbalance (hypoglycaemia etc)
  • Underlying brain tumour, abscess etc.

4. Which diseases are more prone to get epilepsy?
Neurofibromatosis and Tuberous sclerosis

5. Investigations?

6. Complications of tonic clonic seizure?

  • Rhabdomyolysis causing renal failure
  • Respiratory failure (diaphragm tonic)
  • Metabolic acidosis (body uses more oxygen)
  • Hyperpyrexia 

7. Management?

  • Remove any dentures or anything inside mouth
  • KNBM, secure airway
  • Establish lines, give IV Diazepam or Lorazepam to stop seizure
  • Monitor vital sign, Sp02, urine output
  • If patient still has seizure, give another dose of Diazepam after 10 minutes
  • If still not controlled, give Phenytoin
  • If still persist, TRANSFER TO ICU!
  • In ICU, can give another bolus of Phenytoin or Intubate or Phenobarb or Anaesthesia 


  1. Can you post more and more cases like this and the same format. It helps me to revise for my examination.

    1. Hi Haziq, I am not a medical student anymore so I am not sure if I can find time to write long case like this hehe. Goodluck for your exam ya! :D