Friday, January 30, 2015

Long Case with Prof. How

Patient 1

35-year-old intravenous drug user with underlying Hepatitis C, presented with 3 days history of high-grade fever associated with lethargy. Last heroine injection was two days prior admission. Patient had history of needle sharing.

Physical examination revealed a medium build man lying in 45' propped up position. Clubbing was noted. There was no stigmata of IE and no sign of heart failure. Vital signs normal. On cardiovascular examination, JVP was not raised. Pansystolic murmur was heard at left sternal edge, grade 3/6, no radiation, prominent on inspiration, presence of pulsatile liver. Other systemic examinations were normal.

1. Provisional diagnosis?
Infective Endocarditis without complication

2. Complications of IE?

  • Cardiac lesions eg. aortic root abscess leads to complete AV block and left ventricular failure
  • Immune complex deposition eg. vasculitis, glomerulonephritis
  • Embolic phenomenon eg. abscesses in brain, heart, kidney, spleen, gut, lung

3. HIV symptoms and signs?

Taken from this website

4. Investigations?

  • Blood C&S taken 3 sets at different time and site 
  • FBC to check for anemia and leukocytosis
  • UFEME for microscopic haematuria
  • LFT because this patient has Hep C, look at liver enzymes, albumin
  • HIV/VDRL screening
  • ESR/CRP will be raised
  • ECHO to look for any valve vegetations
  • CXR to look for cardiomegaly
  • ECG to look for long PR interval

5. If this patient's albumin is low in LFT, what test do you want to do next?
Do PT/APTT to look at coagulopathy, because low albumin may indicate liver cirrhosis.

6. If this patient's AST and ALT raised, do you want to treat?
Yes, we treat hepatitis by giving PEGinterferon alpha 2a/2b and Ribavirin.

7. Duke criteria for IE?

Taken from this website

8. Which antibiotics you give?

  • For right-sided Staph aureus : Gentamicin + Cloxacillin
  • For left-sided Strep viridans : Gentamicin + Benzylpenicillin

Patient 2

75-year-old female with underlying COPD, bronchiectasis and pulmonary TB on maintenance phase, presented with 3 days history of fever and 2 days history of shortness of breath and haemoptysis.

Physical examination revealed a cachexic elderly female, looked pale and lethargic, on nasal prong. Patient afebrile, RR 30, BP 120/70, HR 84, SpO2 95% under NP. BCG scar present. No leg edema. 

On respiratory examination, trachea shifted to the right. Chest expansion reduced at lower zone of right lung, with reduced air entry, dullness on percussion. Bibasal crepitations present.

On cardiovascular examination, JVP was not raised. Pansystolic murmur was heard at lower left sternal edge.

1. Differentials?

  • Relapse of bronchiectasis
  • Lung carcinoma
  • Aspergilloma

2. Causes of haemoptysis? Remember BATTLE CAMP

  • Bronchitis/Bronchiectasis
  • Aspergillosis
  • TB
  • Tumor
  • Lung abscess
  • Emboli
  • Coagulopathy
  • Autoimmune/alveolar haemorrhage
  • Mitral stenosis
  • Pneumonia

3. Investigation?

4. Management? 
ABC, antipyretic, antibiotic etc.

5. Side effects of anti-TB? Must know ok!

  • Isoniazid : hepatitis, neuropathy, pyridoxine deficit, agranulocytosis
  • Rifampicin : hepatitis, orange discolouration of urine and tears, flu-like syndrome
  • Ethambutol : optic neuritis
  • Pyrazinamide : hepatitis, gout
  • Streptomycin : ototoxicity

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