Case History : A 56 year old woman presenting with shortness of breath

 A 56 year old woman comes to your OPD with complaints of increasing shortness of breath, swelling of feet and tiredness. Her BP is 150/ 100 mmHg.

Your perform a Chest X-ray which is given below:

1. What's are the X ray findings?

2. What is the most likely diagnosis?

3. How would you manage this condition?

4. What other investigations would you like to perform?

Answers given in comments section.

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1. Cardiomegaly / CTR : Cardio thoracic ratio more than 50 %

2. Most likely diagnosis is CCF/ Congestive Cardiac Failure.

3. Management includes: Oxygen , Diuretics such as spiromide +/- intravenous diuresis depending upon severity of CCF and symptoms. Bisoprolol ,Ascard and clotnil to stabilise cardiac function. Salt restriction.

4. Other useful investigations include : Echocardiogram to determine Cardiac status and LVEF and BNP levels in the blood.

Case History : A 65 year old lady comes to your OPD in ED with complaints of pain epigastrium and apprehension

A 65 year old lady comes to your OPD in ED with complaints of pain epigastrium and apprehension since 4 hours. Her BP is 170/100 mmHg. You perform an ECG and the result is attached below.

 

You check her oxygen saturation which is 90 %.

1. What are the findings in ECG.

2. What emergency treatment would you give?

3. What is the most likely diagnosis?

4. What other investigations would you like to perform?

5. How will you manage this patient further?

 

Answers given in comments section.

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1. What are ECG findings : 

ST elevation in chest leads with T wave inversions and broad QRS complexes.

 2. What emergency treatment should be given to patient?

1. Analgesic ( opioid eg Inj Tramal intramuscular)

2. High flow oxygen

3. Aspirin and Clopidrogel.

4. Glyceryl Tri nitrate eg Cardnit or sustac 2.6 mg

5. Lower blood pressure with sub lingual Capoten 25 mg stat.

3. Most likely Diagnosis ? 

Acute coronary syndrome / Acute myocardial infarction.

4. What other investigations would you like to perform?

Troponin T and Troponin I levels.

Cardiac enzymes like CK MB, LDH

Chest X-ray and echocardiogram to ascertain Cardiac Failure status

Urea, cholesterol and blood sugar levels.

5. Further management : 

After giving above emergency treatment, refer the patient to a Cardiac Care unit / CCU in a nearby tertiary health care facility for further management.

Case History : A 45 year old female complains of fullness in her right hypochondrium

A 45 year old female complains of fullness in her right hypochondrium since 5 months.There is no associated history of pain epigastrium or burning. Her Blood pressure is 140/90 mmHg and there are xanthelasmas on her eyelids.

1. What investigations would you like to perform?

2. What are the findings on ultrasound?

3. What additional investigations would you conduct keeping in mind the ultrasound findings?

4. What is the most likely diagnosis?

5. How will you treat this condition?

Answers in comments.

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1. Investigations to perform:

Blood Cholesterol levels.

Blood sugar levels.

Abdomen ultrasound.

As this patient has moderately high BP and presence of Xanthelasmas, we would measure serum cholesterol levels and blood sugar levels which not uncommonly exist together with hypertension.

Also patient has got fullness of right hypochondrium so it might be a good idea to conduct an ultrasound of abdomen to exclude any hepatic or gall bladder pathology here.

2. Ultrasound findings:

There is increased echogenicity of liver. Usually kidney and liver have equal echogenicity, in this case liver echogenicity is more .

3. Liver function tests , inclusive of Bilirubin, Alanine Transaminase and Alkaline phosphatase. Also it might be a good idea to conduct Hepatitis B and C levels.

4. Fatty Liver / Non alcoholic Steatotic Hepatitis

5. Management :

Low cholesterol diet

Exercise

Eat plenty of fruit and vegetables.

Case History : Female coming with Difficulty Breathing

A 65 year old female comes to your Acute Medicine OPD complaining of difficulty breathing for last 5 days and productive cough. She has a fever of 37.5 C. On auscultation, you can hear wheeze in right lung field but reduced air entry in the left lung.

She does have a past history of Asthma and Tuberculosis during adult years.

1.Which investigations would you like to perform?

2. What is the most likely Diagnosis?

3. How will you manage this condition?

4. What are the X ray findings?

Answers given in comments section.

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1. Which investigations would you like to perform?

Chest X ray

Measurements of oxygen saturation

Arterial blood gases

Sputum for AFB and Culture and sensitivity.

ICT TB

Quantiferon TB test

2. What is the most likely diagnosis?

Acute Asthmatic attack

Post TB Bronchiectasis

TB flare up

3. How would you manage this condition.

Give regular nebulization Is Salbutamol and Clenil A nebs

Intravenous hydrocortisone

Oxygen

Intravenous antibiotics. Lung Physiotherapy

In case of acidosis on Arterial blood gas, NIV/ Non Invasive ventilation may be needed.

4. What are the X ray findings?

Absent left lung / pneumonectomy due to most likely as part of treatment for Tuberculous lung damage.

Hyperinflation of right lung as a result of compensation to left pneumonectomy or due to emphysema or post TB Bronchiectasis.

Case History Theme : Pruritis

 Case History

Theme : Pruritis

A 55 year old female presents to you with complaints of pruritis and rash over her lower legs.

According to her she has also lost weight recently.

She says that that she took ponston forte tablet and afterwards she developed pruritis and lesions on skin.

She also complains of developing constipation at times as well and abdominal distension.

You look at her investigations and find Anti HCV test positive in one of lab reports.

On asking about Anti HCV result , she says she received some treatment for it for about 6 months but has no record of it/.

What is the most likely cause of her pruritis ?

Which investigations would you like to order?

Answers given in comments section

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Question 1 :

What is the most likely cause of her pruritis ? There are two possibilities :

1. Allergic reaction due to Ponstan forte / Mefenamic acid

2. Chronic liver disease causing raised bile salts leading to pruritis.

Question 2 : Which investigations would you like to order?

1. Ultrasound of abdomen

2. HCV by ELISA method

3. HCV PCR qualitative.

As is given in the history, the patient has Anti HCV Serology positive. However she has not told anything about her treatment whether she was given proper treatment with antiviral medications or just supportive treatment was given .

Hence it is important that her investigations need to be done including HCV PCR and ELISA methods to confirm definite diagnosis of hepatitis C Infection.

Also , we need to exclude chronic liver disease by examining for presence of ascites and ordering an ultrasound of abdomen which will show presence of cirrhosis/ coarse echo texture and ascites , splenomegaly and increased portal vein diameter.

Intense itching could be due to bile products being deposited in the skin . The scarring of the liver in chronic liver disease causes an increase in blood levels of a coloured pigment called bilirubin that is normally secreted by liver cells.

Also advise patient against use of ponstan forte in future as it could be very likely this was just an allergic reaction to Ponston forte in case all investigations for hepatitis C are found to be negative ie ELISA and PCR and Ultrasound abdomen is normal.

Cardiology Made Simple : Cabrera’s sign

Cabrera’s sign is used to diagnose an acute myocardial infarction in the setting of a left bundle branch block and consists of notching at 40 milliseconds in the upslope of the S wave in lead V3 and V4. This has a poor sensitivity of 27% for myocardial infarction.

Determining the presence of an acute myocardial infarction when a patient has a baseline left bundle branch block present is difficult. Besides the Cabrera’s sign, the Sgarbossa criteria and the Chapman's sign can be helpful.

Case History : A 40 year old male comes to ER department with chest pain since last 40 minutes.

 Case History :

A 40 year old male comes to ER department with chest pain since last 40 minutes.

Which immediate investigations would you advise :

Troponin T levels

ECG

What would be next step of management :

High Flow oxygen

Aspirin 300 mg stat.

What other medications should be given ?

Morphine for pain

GTN / Glyceryl tri nitrate

ECG shows ST Elevation and Bloods come back with raised Troponin T levels.

What does this imply ?

ST elevation means the clot thrombus has already been stabilized and occluded the blood vessel.

Hence the aim is to break down the thrombus.

Therefore we need to proceed with thrombolysis with Tissue Plasminogen Activator / TPA and proceed with PCI / Percutaneous Coronary Intervention ( Angiography + Angioplasty where applicable ) .

What is the Diagnosis of this patient :

Acute Coronary Syndrome / Acute Myocardial Infarction

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