Thursday, January 22, 2015

Short Case with Dr. Kuan

Patient 1

Middle-aged man, medium build, lying 45' on nasal prong 3L/min, looked tachypneic. Clubbing of fingers noted with tar staining at left fourth finger. Chest expansion was reduced at both lower lungs. Lungs were hyperresonant on percussion. Fine crepitations heard bilaterally. 

1. Causes of lower lobe fibrosis? CRABSS
Cryptogenic fibrosing alveolitis, RA, Asbestosis, Bleomycin, SLE, Scleroderma

2. Causes of clubbing?
Lung carcinoma, empyema, abscess, bronchiectasis, IE, congenital heart disease, Chron's

3. Investigations?
FBC, BUSE, sputum C&S, ABG, spirometry, high resolution CT

4. Provisional diagnosis?

Patient 2

Patient had left homonymous hemianopia.

1. How do you test patient's eyes?
Test cranial nerve 2, 3, 4 and 6.
Read complete examination at this website.

2. Complete examination with?
Funduscopy, UL and LL neurological examination

3. Provisional diagnosis?
Left homonymous hemianopia secondary to lesion at parietal or occipital of right-sided brain.

4. How do you know the lesion is on the right side?
Trace back the pathway. In this patient, the lesion is at number 3 (right side of brain), so the patient has left homonymous hemianopia (patient cannot see temporal of left eye and nasal of right eye). Understand the diagram ok!

5. Differentials?
  • Cortical stroke at right cerebral hemisphere
  • Space-occupying lesions eg. tumour, abscess, cyst, bleeding

6. Management of ischaemic stroke?
  • Admit patient to ward
  • Swallowing test, check gag reflex for nutrition 
  • Monitor vital signs, urine output
  • Screen for risk factors eg. HPT, DM, IHD, HPL
  • Do ECHO and carotid artery Doppler to look for cause
  • DVT prophylaxis and prevention of bed sore
  • Aspirin + statin, Thrombolysis
  • Patient education, moral and psychosocial support
  • Chest and limb physiotherapy
  • Refer dietician

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