Thursday, January 15, 2015

Short Case with Dr. Hadzri

Patient 1

A 57-year-old Malay man, sitting 90' on bed with 2 pillows, looked lethargic and had Internal Jugular Catheter at his right side of neck. He presented with multiple tophi at hand, elbow and ankle joint. Knee joints were tender and swollen. Onycholysis of toes were seen. No psoriatic patch on scalp or skin, no tophi at pinna of the ear.

1. How do you do hands examination?
Remember to LOOK, FEEL and MOVE. Read the details in textbook.

2. What differentials can you think in this patient who has IJC?
  • Chronic kidney disease secondary to gout
  • Rheumatoid Arthritis
  • Systemic Lupus Erythematous
  • Diabetic nephropathy 

3. Full provisional diagnosis?
Gouty tophi deposits of hand, elbow and ankle joints

4. Causes of gout?
Can be due to increase production of uric acid or reduce excretion of uric acid.

5. How do you confirm it's gout, not pseudogout?
Aspirate the synovial fluid. We can see needle-shape monosodium urate crystals, negative birefringent under polarized light microscopy = diagnosis of gout. If we see rhomboid-shape calcium pyrophosphate dihydrate crystals, positive birefringence, it's pseudogout. 

Patient 2

A middle-aged Malay man presented with left lower limb weakness, hypotonia, power 2/5 and hyperreflexia. No clonus, plantar upgoing. No muscle wasting or fasciculation. Sensation intact.

1. Do lower limb neurological examination.
  • Inspect for abnormal posture, muscle wasting, scars, dilated veins 
  • Check for fasciculation
  • Tone, Power, Reflex
  • Clonus, Babinski
  • Sensation, Proprioception
  • Heel-to-shin test

2. Differentials?
Right CVA - ischaemic or haemorrhagic stroke, space-occupying lesions, etc.

Ward Round

1. Indications for acute dialysis?
  • Acute Pulmonary Oedema
  • Hyperkalemia
  • Severe metabolic acidosis
  • Uremic encephalopathy
  • Uremic pericarditis

2. Hypernatremia?

Taken from Oxford Handbook of Clinical Medicine 8th Edition

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