Friday, February 06, 2015

Long Case with Dr. Khairul Azhar

Patient 1

29-year-old female with underlying Beta Thalassemia and Diabetes Mellitus, presented with 8 days history of fever and cough, associated with 1 day history of polyphagia, polydipsia and polyuria. She missed her insulin injections one day prior admission.

Physical examination revealed a thin built lady (BMI 18), pale, lethargic and dehydrated. She had Thalassemic facies and skin hyperpigmentation. BP 100/60, RR 18, PR 88, SpO2 98% under room air, Dxt 11. 

Positive findings : 
  • Respiratory - right middle and lower zone reduce chest expansion and air entry. Increase vocal fremitus and vocal resonance. Dull on percussion with crepitations heard.
  • Cardiovascular - cardiomegaly
  • Abdomen - hepatomegaly

1. Provisional diagnosis?
  • Diabetic Ketoacidosis secondary to Community Acquired Pneumonia 
  • Underlying Beta Thalassemia
  • Cardiomyopathy secondary to iron overload

2. Investigations?
RBS, FBS, HbAIc, UFEME, VBG, FBC, RP, Blood Ca/Mg/Phos, LFT, PT/APTT, Blood C&S, CXR, US HBS

3. Management?
Acute
  • Stabilise patient - resuscitate
  • Oxygen therapy - nasal prong
  • Allow orally, strict DM diet
  • Strict urine chart, vital signs monitoring
For DKA
  • Manage fluid loss
  • Treat hyperglycaemia
  • Treat electrolyte imbalance
  • Treat precipitating cause
For CAP
  • Give IV Rocephine

4. Complications?
Taken from this website


Patient 2

55-year-old man with underlying chronic liver disease and hepatitis B, presented with 3 days history of fever, abdominal distention and bilateral leg swelling, associated with jaundice and tea-coloured urine. 

Physical examination revealed a medium build man with generalised jaundice and bilateral leg edema, on nasal prong. T 38, BP 117/81, HR 73, RR 32. Abdomen distended, shifting dullness positive. No hepatomegaly or stigmata of chronic liver disease. Other system examinations showed no evidence of heart failure, pleural effusion or hepatic encephalopathy.

1. Provisional diagnosis?
Spontaneous Bacterial Peritonitis secondary to decompensated liver cirrhosis

2. Investigations?
LFT, US HBS, UFEME, Viral serology, GGT, ANA, FBC, RBS, PT/APTT, Abdominocentesis, OGDS, AFP

3. Serum Albumin - Ascites Albumin?
If > 1.1 = portal hypertension (transudative ascites)
If < 1.1 = other causes (exudative ascites)
Taken from this website

4. Grade of hepatic encephalopathy?
Table 1: Clinical grades of hepatic encephalopathy
Taken from this website

5. Causes of hepatic encephalopathy?
Taken from this website

6. Child Pugh score?
Taken from this website

7. Management?
This patient's problem is SBP, so give antibiotics. The main thing is to prevent any factors that lead to hepatic encephalopathy.

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