Monday, February 09, 2015

Long Case with Dr. Hilmi

Patient 1

Mrs. H, a 36-year-old Malay lady with underlying Systemic Lupus Erythematosus and Type 2 Diabetes Mellitus, presented with one week history of worsening skin rashes, associated with mild fever, arthragia, alopecia and oral ulcers.

Physical examination revealed a medium build lady with discoid erythematous rash over cheeks, forehead, ears, scalp, both arms and upper chest. She was not pale and no bleeding tendency noted. Multiple oral ulcers were present with dry lips. Arthralgia noted at MCP and PIP joints of both hands. No evidence of pleural or pericardial effusion.

1. Differential diagnoses?
  • Infective causes of rash such as URTI, measles, chicken pox, rickettsial infection, TSS
  • Drug-induced rash such as ampicillin, ceftriaxone, levofloxacin, carbamazepine, NSAIDs
  • Henoch-Scholein Purpura

2. Investigations?
RBC, RP, LFT, PT/APTT, FBS, HbA1c, ESR, CK, CRP

3. Management?

  • General - admit patient, refer rheumatologist, trace old clinical notes, vital signs monitoring, intravenous hydration, dextrostix QID
  • Pharmacology - IV methylprednisolone 500mg OD for 3 days, continue old medications, add T. Omeprazole 20mg OD for gastro protection, add T. Piriton 8mg ON for itchy skin rash
  • Non-pharmacology - advise patient to use sunscreen, wear hat or umbrella when exposed to sunlight, patient education, stress on compliance  

4. Precipitating factors that can cause SLE flare?


  • UV rays from sun or fluorescent light bulbs
  • Drugs eg. sulfa drugs, diuretics, tetracycline, penicillin
  • Infection
  • Exhaustion
  • Emotional stress eg. divorce, life complications
  • Physical stress eg. surgery, pregnancy, physical harm


5. Types of SLE?

  • Cutaneous lupus
  • Systemic lupus
  • Drug-induced lupus
  • Neonatal lupus


Patient 2

Mr. R, a 62-year-old man, presented with one month history of anterior neck swelling associated with fever, lethargy and weight loss.

Physical examination revealed multiple lymphadenopathy at right cervical, axillary and inguinal region. No hepatomegaly, focal neurological deficit, pericardial or pleural effusion.

1. Provisional diagnosis?
Lymphoma

2. Ddx?

  • TB lymphadenitis
  • Leukaemia
  • Secondary metastasis

3. Investigations?
Lymph node biopsy, FBP, FBC etc.

4. Management?
ABVD for Hodgkin and RCHOP for non-Hodgkin

5. What are B symptoms?
Unexplained fever, lethargy, weight loss, night sweats, pruritus

6. Side effects of chemotherapy drugs?
Taken from this website and this website 

General

  • Neutropenia causing infection
  • Thrombocytopenia causing bruising and bleeding
  • Anemia causing lethargy, shortness of breath
  • Nausea and vomiting
  • Lethargy
  • Flu-like symptoms
  • Hair loss
  • Sore mouth and oral ulcers
  • Nail changes eg. brittle, discoloured
  • Deranged renal and liver profile 
  • Raised serum uric acid due to rapid breakdown of cancer cells

Specific

  • Bleomycin : rash
  • Vinblastine : vision problem
  • Vincristine : peripheral neuropathy, constipation 
  • Doxorubicin : discoloured urine, pink-red urine for up to 48h
  • Cyclophosphamide : bladder irritation, dysuria
  • Steroids : hyperglycaemia, indigestion, weight gain, leg swelling

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