Tuesday, February 03, 2015

Short Case with Dr. Vova

Patient 1

Middle-aged man lying down in 45' propped up position, looked cachexic and lethargic. He was on intravenous infusion of Amoxicillin. 

On hands examination, there were Janeway lesions and Osler nodes noted, no clubbing or splinter hamorrhage. Pulse rate normal, regular rate, rhythm and volume. No radio-radial delay, no radio-femoral delay, collapsing or bounding pulse. He had tattoo on right arm. No obvious injection marks seen. 

On face examination, he had subconjuctival pallor, but no jaundice. Oral hygiene was fair, no oral thrush seen. JVP was not raised. On feet examination, no pedal edema noted.

On cardiovascular examination, no surgical scar or dilated veins noted. Obvious pulsating beat was seen at mitral area. No palpable thrill or parasternal heave felt. On auscultation, pansystolic murmur was heard at lower left sternal edge, best heard during inspiration, grade 3/5.

1. Provisional diagnosis?
Tricuspid regurgitation secondary to infective endocarditis

2. Investigations?
Blood culture taken 3x at different site and time, 12h apart, FBC, UFEME, RP, ECHO, ECG

3. Management?
This is a right-sided endocarditis, possible organism would be Staph aureus, so we give Gentamicin and Amoxicillin for 4-6 weeks.

Patient 2

Thin build male adult, sitting up on hospital bed, looked lethargic. On cerebellar examination, patient had no horizontal or vertical nystagmus. He had staccato speech. He had intentional tremor, more prominent on the right hands. Dysdiadochokinesia was also more prominent on right side. No rebound tenderness. Patient can perform heel-to-shin test.

Patient cannot stand up, so his gait could not be assessed.

1. Provisional diagnosis?
Right cerebellar lesion

2. Differentials?
Lesion can be infarct, hemorrhage, tumor. Demyelinating disease like MS. Bulbar palsy.

3. Investigations?
CT brain, MRI brain, FBC, BUSE etc.

4. In Multiple Sclerosis, what treatment do you give?
Intravenous immunoglobulin, high dose intravenous methylprednisolone or plasmapheresis

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