Monday, February 16, 2015

Short Case with Dr. Hasnur

Patient 1

Middle-aged man who looked lethargic, dehydrated and in pain. He was pale. Abdomen distended with fullness of flanks. Hepatosplenomegaly present.

1. Causes of hepatosplenomegaly?

Haematological
+ Myeloproliferative - Myelofibrosis, CML, PCV, essential thrombocytosis
+ Lymphoproliferative - ALL, CLL, lymphoma, myeloma
+ Haemolytic anemia

Infection
+ Infectious hepatitis
+ Infectious mononucleosis
+ Leptospirosis
+ Malaria
+ Toxoplasmosis
+ Leishmaniasis

Portal hypertension

Others 
+ Sarcoidosis
+ Amyloidosis 

2. Investigations?
FBC, FBP, LFT, AFP, VDRL/Hep B and C/HIV, Liver US, CT scan of liver


Patient 2

Middle-aged man with left hemiparesis.

1. Differential diagnoses?

Stroke
+ Ischaemic 
+ Haemorrhagic

Space-occupying lesions
+ Tumour
+ Abscess
+ Hemangioma
+ Aneurysm

2. Examples of UMN and LMN lesions

Taken from this website

3. How to test a patient with Parkinson Disease? 
Remember TRAP : Tremor, Rigidity, Akinesia, Postural instability

First, ask patient to walk to assess gait. He will have shuffling gait, reduced length of steps, reduced arm swing, stooped posture, hard to initiate movement, difficult to turn and stop abruptly. Look for masked facies.

Assess postural instability. Do pull test - pull patient backwards, ask him to resist and don't fall. He will take 4-5 steps backwards before he comes to rest.

Second, ask patient to sit down on a chair and put hands on a pillow to assess tremor. Look at pill-rolling tremor. Accentuate tremor by asking his name or ask to count from 100 backwards.

Look for other types of tremor such as resting tremor, intentional tremor (do past-pointing) and postural tremor (ask patient to lift both arms and look of there's tremor).

Check tone. Look for rigidity. Leadpipe is sustained resistance throughout whole range of motion while cogwheel is jerky resistance to passive movement. Clasp knife is rigidity that presents only at the start of passive movement, rate dependent and velocity-dependent.

Check bradykinesia. Ask patient to touch pointing finger to thumb repeatedly, play piano, grip and open grip or do foot tapping repeatedly. Look for slowness of movements.

Look for signs of Parkinson plus syndrome such as cerebellar sign (positive finger-nose test and positive Babinski in MSA) and eye sign (vertical gaze palsy in PCP).

Do glabellar tap. Tap in between eyes repeatedly. Patient will keep blinking.

Ask patient to write. Look for micrographia (small handwriting).

This video explains how to assess a patient with Parkinson. At the end of the video, look at how the neurologist does pull test and you can see the patient reacts.


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