A 45 year old female presents to your OPD with complaints of pain in her left shoulder and numbness of left arm . She says the pain radiates to anterior and left side of her chest.

 A 45 year old female presents to your OPD with complaints of pain in her left shoulder and numbness of left arm . She says the pain radiates to anterior and left side of her chest.

She also gets short of breath and swelling of her legs on walking.

On clinical examination, her BP is 140/80 mHg and Oxygen saturation is 96 % on air. Her respiratory rate is 14 / minutes.

There is no pedal oedema , JVP is not raised .

She appears Obese .

Auscultation of the lungs reveal no crepitations or added sounds and bilateral equal air entry in both lung fields.

You decide to organize some investigations.

1 .Which Investigations would you organize in her case ?

2 . What could be the most likely Diagnosis in this case ?

3 . What are the management options for this patient ?

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Answers given in comments section.

1 .Which Investigations would you organize in her case ?

Chest X ray : To visualize lung fields and heart size which will give us an idea of Congestive Cardiac Failure.

ECG : To exclude Ischaemic heart disease as the patient although complains of Pain in shoulder , but she does say it radiates to left side of her chest and also there is high Blood pressure and symptoms suggestive of CCF which can co- exist with IHD.

X ray of left shoulder to exclude presence of arthritis.

Her Blood Pressure is High hence it might be a good idea to organize Random Sugar Levels , Cholesterol levels or Lipid Profile , Uric acid and Renal function Tests Including EGFR , Urea and Creatinine and serum albumin levels apart from Full Blood Count and serum Haemoglobin.

2 . What could be the most likely Diagnosis in this case ?

While the Chest X ray and ECG show no obvious pathology ,most likely Diagnosis : left frozen shoulder / Adhesive capsulitits as can be seen by X ray findings where the head of humerus seems to be trapped in the shoulder joint.

Frozen shoulder, also known as adhesive capsulitis, is a condition characterized by stiffness and pain in your shoulder joint.

Signs and symptoms typically begin gradually, worsen over time and then resolve, usually within one to three years.

3 . What are the management options for this patient ?

Therapy

A physical therapist can teach patient range-of-motion exercises to help recover as much mobility in the shoulder as possible.

Surgical and other procedures :

Most frozen shoulders get better on their own within 12 to 18 months. For persistent symptoms, folllowing are useful :

Steroid injections. Injecting corticosteroids into shoulder joint may help decrease pain and improve shoulder mobility, especially in the early stages of the process.

Joint distension. Injecting sterile water into the joint capsule can help stretch the tissue and make it easier to move the joint.

Shoulder manipulation. Ithe doctor moves your shoulder joint in different directions, to help loosen the tightened tissue.

Surgery. Surgery for frozen shoulder is rare, but if nothing else has helped, surgery to remove scar tissue and adhesions from inside your shoulder joint may be done. Doctors usually perform this surgery with lighted, tubular instruments inserted through small incisions around shoulder joint (arthroscopically).

        
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A 25 year old man comes to your OPD with complaints of weakness, spells of dizziness, and shortness of breath on walking.

 A 25 year old man comes to your OPD with complaints of weakness, spells of dizziness, and shortness of breath on walking.

He occasionally gets palpitations as well. On checking his oxygen saturation, it is 84 percent. His BP is 120/70 mmHg and there is no oedema of the legs.

On Auscultation of the heart , you hear a pansystolic murmur.

On examination of his hands, you note the findings given below:

1. What are the findings in the hands?

2. What is the most likely Diagnosis?

3. What causes this disease?

4. Which investigations should be performed?

5. What are the complications of this condition?

6 .What are the management options for this patient?

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1. Clinical findings in the hands:

Clubbing

Peripheral Cyanosis

2. Most likely Diagnosis:

Ventricular septal defect with development of Eisenmenger syndrome.

Individuals with Eisenmenger syndrome often have a ventricular septal defect or a “hole in the heart” between the left and right pumping chambers in the heart.

This results in significant shunting of blood from the left side of the heart to the right at birth, which progresses to pulmonary vascular disease.

Symptoms of Eisenmenger syndrome vary depending on the heart defect and affected organs. They do not usually occur until people are in their teens, 20s or 30s. The signs slowly get worse.

3. Causes of Ventricular Septal Defect :

Chromosomal abnormalities / Genetic causes.

Poor Diabetes control during pregnancy.

Infections during pregnancy.

Medications having side effects, consumed during pregnancy.

Increased smoking and alcohol consumption during pregnancy.

4. Investigations to be performed:

Full Blood Count

Clinical examination

Oxygen saturation / Pulse oximetry

ECG

Chest X ray.

Echocardiogram (Simple) and Transesophageal Echocardiogram / TOE

Cardiac CT scan and MRI.

5. Complications :

Cyanotic spells

Infective Endocarditis

Polycythemia

Septic emboli

Clubbing

Paradoxical embolization.

Brain abscess

Haemoptysis.

6. Management:

Usually, in congenital VSD / Ventricular septal defect , surgery should be performed in the first year of life and includes closure of the Ventricular septal defect and surgical correction of other co-existent abnormalities.

However as this patient wasn't treated with surgery during childhood, his treatment would now mainly be Pharmacological and includes medications from the below categories :

A. ACE Inhibitors like captopril and lisinopril are used to treat CCF and Hypertension that develops in this disease.

B . Betablockers such as Atenolol, Carvedilol and Bisoprolol are used to treat Hypertension, but in this case can be used to treat cardiac arrhythmias.

C. Antiplatelets such as Aspirin and Clopidrogel are used to prevent development of thrombosis and subsequent Stroke or Myocardial infarction.

There is a high chance of these incidents in patients with VSD due to persistent Hypoxia.

Other medications include

Sildenafil to treat arterial hypertension.

Diuretics to reduce load on heart.

Bosentan to treat pulmonary hypertension

And Digoxin to treat irregular heart beats

Further Reading : https://www.mayoclinic.org/.../symptoms-causes/syc-20350580

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A 45 year old female presents with pain in abdomen on right side, after eating meals and distension as well. She also complains of right hypochondrium fullness.

 A 45 year old female presents with pain in abdomen on right side, after eating meals and distension as well. She also complains of right hypochondrium fullness. Her Blood pressure is 150/80 mmHg.

You decide to perform an Ultrasound of abdomen which is shown below:

1. What are the findings in the Ultrasound?

2. What further investigations should be performed?

3. What should be the management options in this patient?

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1. What are the findings in the Ultrasound?

Ultrasound findings:

A single 26 mm gall stone

Gall bladder wall thickness of 2 mm suggestive of chronic inflammation.

Fatty liver

2. Further investigations:

As patient has high Blood pressure as well with gall and fatty liver, blood cholesterol levels and Random blood sugar levels should also be done.

In addition, ECG, Chest X ray and pre operation procedures should be organized as patient may require surgery after a surgical input . Anesthesia fitness maybe needed as well.

3. Management options:

Surgery maybe required, hence surgical input is important for cholecystectomy.

Opiate analgesics and antiemetics with smooth muscle relaxants would be beneficial management options.

Blood pressure should be controlled and healthy life style should be adopted.

Fatty meals should be avoided and high cholesterol and sugar diets should also be avoided.

 A 45 year old female presents with 2 hour history of left sided chest pain .

You conduct an ECG which is shown below:

1. What are the findings in the ECG?

2. What are the causes of these findings?

3. Which further investigations should be performed next?

4. What are the management options?

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1. ECG Findings:

ST elevation in V1 to V3.

ST depression in V5 - V6.

2. What are the causes of these ECG Findings :

V1 - V3 ST elevation is suggestive of Right ventricular Myocardial infarction.

V5-V6 ST depression is suggestive of severe Coronary artery disease in Left Anterior Descending artery or its diagonal branch.

3 . Further Investigations :

Troponin T levels and Myoglobin levels.

4. Management options:

Load patient with Aspirin and Clopidrogel.

Early Angiography and PCI / Primary Coronary intervention/ Angioplasty +/- stent placement.

Fondaparinux as per ACS protocol.

A 28 year old man presents with difficulty in breathing and orthopnea since last 30 days .

 A 28 year old man presents with difficulty in breathing and orthopnea since last 30 days .

He had been treated for pneumonia 2 months ago .

At the moment he denies any sputum production , but at times gets right sided chest pain.

He is afebrile, and oxygen saturation is 97 percent on air.

A chest X ray is done which is shown below:

1. What is the most likely Diagnosis? / Findings on chest X - ray?

2. What are the causes of this condition?

3. Which further investigations should be performed?

4. What are the treatment options of this condition?

5. What are differential diagnosis of this condition?

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1. 1. What is the most likely Diagnosis? / Findings on chest X - ray? :

Chest X ray findings include elevated Right hemi-diaphragm .

Most likely Diagnosis is Right sided phrenic nerve palsy.

2. Causes of phrenic nerve palsy:

This occurs due to lesions anywhere along the course of the phrenic nerve as it travels from the neck to pierce the diaphragm adjacent to the pericardium.

Causes include :

idiopathic or post viral.

Other causes include:

Inflammatory causes :

Pneumonia

Pleurisy

Empyema

Herpes zoster infection.

Direct Compression;

Aortic aneurysm

Cervical osteophytes.

Neuromuscular Disease:

Chronic inflammatory demyelinating polyradiculopathy.

Trauma and Iatrogenic:

Penetrating injury

Chiropractic manipulation

Malignancy :

Pulmonary metastasis.

Bronchogenic carcinoma.

3. Which further investigations should be performed?

Fluoroscopic examination of the diaphragm ( sniff test).

CT chest : helps to identify the cause of phrenic nerve palsy eg pneumonia, haematoma ,space occupying lesions etc.

MRI can help in evaluation of Pancoast tumors.

Conduction and electromyographic studies.

4 Treatment options:

Deep breathing and hold the breath.

Treatment of underlying cause.

Diaphragmatic pacing in case of symptomatic unilateral cases or bilateral involvement.

5. Differential Diagnosis of Phrenic nerve palsy:

Masses / collections pushing the diaphragm up from below:

Hepatic mass

Sub phrenic collection

Intra abdominal fat

Reduced volume of lung pulling the diaphragm up:

Lobectomy

Radiation induced fibrosis.

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