Wednesday, February 18, 2015

Short Case with Dr. Anis

Patient 1

Middle-aged man, alert and conscious, cooperative, comfortably lying on bed. Tattoos noted at both arms. There were finger clubbing, leukonychia, jaundice, pallor and hepatomegaly.

1. Provisional diagnosis?
Chronic Liver Disease

2. How do you grade clubbing?
Grade 1 : fluctuation of nail bed
Grade 2 : loss of angle
Grade 3 : increase nail curvature
Grade 4 : soft tissue swelling, drumstick appearance
Grade 5 : presence of HPOA

3. Causes of fine tremor?
+ Beta agonist use
+ Hyperthyroidism
+ Anxiety
+ Senile tremor

4. Causes of flapping tremor?
+ Uremic encephalopathy
+ Carbon dioxide retention

5. Investigations?
FBC, LFT, PT/APTT, HepB/C serology, GGT, Liver US

6. Symptoms of hepatic encephalopathy?
Agitated, restless, confused, drowsy, personality change, seizure, coma

7. How do you test if patient has hepatic encephalopathy?
Ask patient to draw a 5-pointed star, he cannot join the lines together - constructional apraxia

8. How do you manage patients with hepatic encephalopathy?
  • Nil by mouth - parenteral nutrition
  • Low protein diet
  • Lactulose to clear bowel
  • Metronidazole to reduce gut flora
  • Prevention of factors that will aggravate it like trauma, bleeding, infection, constipation, surgery, alcohol, analgesic, hypokalemia
  • Patient education


Patient 2

Middle-aged man who looked tachypneic evidenced by intercostal recession and use of accessory muscles. Trachea was centrally located. Respiratory examination findings were confined to the right middle and lower zone : reduced chest expansion, absent breath sounds, reduced vocal resonance and vocal fremitus as well as stony dullness on percussion.

1. Provisional diagnosis?
Right pleural effusion

2. Causes of pleural effusion? Taken from UM X'Press
  • Transudate - cardiac failure, nephrotic syndrome, chronic liver disease
  • Exudate - malignancy, pneumonia, TB, pulmonary infarction, connective tissue disease
  • Hemorrhagic - malignancy, pulmonary embolism, trauma
  • Empyema - lung infection (pneumonia, abscess), chest trauma, thoracic surgery, subdiaphragmatic abscess
  • Chylothorax - malignancy (lymphoma), trauma
3. Investigations?
  • CXR/US - helps in finding the best site for pleural tap
  • Pleural tap and fluid analysis - protein, LDH, glucose, gram stain, Ziehl-Neelsen stain, culture/cytology, adenosine deaminase
  • Percutaneous pleural biopsy - indicated in undiagnosed pleural exudates with non-diagnostic cytology and clinical suspicion of TB or malignancy

4. How do you do Mantoux test? Taken from this website
Inject 0.1ml of purified protein derivative (PPD) intradermally. Mark the area and wait for 48h to 72h. Look if there is any induration (firm, raised, palpable). Measure it. If it is more than 10 mm, it is positive. If it is more than 15 mm, it strongly suggests active TB.

5. False positive?
+ Infection with non-TB mycobacteria
+ Previous BCG vaccination

6. False negative?
+ Recent TB infection (within 8-10 weeks of exposure)
+ Recent live-virus vaccination (eg. measles and chickenpox)
+ Very old TB infection (many years)
+ Very young age (less than 6 months old)
+ Overwhelming TB disease

7. Examples of second-line anti TB medications?
+ Ofloxacin
+ Clarithromycin
+ Minocycline

8. What are primary and secondary drug resistant TB?
Primary means the patient got infected by someone who has drug resistant TB. Secondary means the patient is on anti TB but not compliant, so he develops drug resistant TB. 

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