Long case PCM

1.chiefcomplaintrightbigtoeswelling1stpresentation(10yearsago)
briefhistoryduringthe10years,multiplejointinvolveaswell.buteverytime1joint...assstiffand
affectfunction..ambulatingwheelchairafter3attack..lastattack2yearsago,rightkneepainass
swellingandfever..backgroundhistoryofHPT.
PEfindingcushingfacies+uallnoe,deformityfinger(boutonnier),fixleftanklejoint.
diagnosisgoutyarthritis,uncontrolHPT,steroidcozcushingnmaybmetabolic
questionsaskedbylecturerwhatinvestigationuwanttodo?hewantESRandCRPanduricacid...
isituricacidnormalmeantnogout?no
whicjointaspirationuwanttotake?midsizejoint
whatuseeinaspiration?monosodiumuratecrystal,negativebirefringent..
howuliketomanage?NSAIDSindomethacin
S/ENSAIDS?UGIB,gastritis,...
othersTXallopurinol..whenuwantostart?afterdacuteattack?why??ianswerwillaggravatedd
acutestate..thenprofsaidnwm..isHIGH5
othersMxrehydration,dietandcontrolHPT..
whatdouthinkabouttheMedCompliance...
howuassessdcompliancemedofthispatient?

2.chiefcomplaint:comeforexam.currentlyunderfollowupfor:
endometrialCa(postTAHBSO)
asthma
deepveinthrombosis
obesityandDiabetesMellitus(inimainproblemdia)
briefhistory
suhaili,35,malay,lady
a)asthma,sincechildhood,wellcontrolled,currentlyonbicotideandventolin
b)dvt,currentlyonwarfarin8mgOD,INR:23,wellcontrolled
c)endoMCa,doneTAHBSO,15roundofchemo,andbrachytherapy.currentlywell,nosignof

mets/recurrence
d)Diabetes:currentlyonmetformin850mg,diamicron1tabletOD,insulatard10Ubeforebed.last
followupHBA1cis12.1.Poorlycontrol.claimtakemedicationandcontrolldiet.howeverdonot
exercise.
PEfinding(positivefindingonly)
randombloodsugar:13.1mmol/l
obese:BMI37.37
leftlegswellingwithvaricosevein
diagnosis
uncontrolledDMwithobesity.andcurrentlyonmedicationforDVT
questionsaskedbylecturer
duringPE:demonstratehowuconfirmswelling,whatisthecausesofunilaterallegswelling,when
patientstartedtodevelopdiabeticneuropathyasthispatientonlydiasnosedDMincidentallyfor3
years,whatcanbethecausesoftheswellinginthispatient(lymphoedema???)
backinroom:whatisthecurrentstatusofherDVT,whatisthepatientcurrentconcern
(uncontrolledDM),ifHBA1cis11.1whatdoesitmeans,whatotherinvestigationwouldyoudofor
thispatient,inUFEMEifprotein1+whatdoesitmeans,(contamination??UTI??),howtoruleout
this,otherinvestigation,giveallotherinvestigationandmanagamentforDMinthispatient.(ting
tong...timesup).that'sallimanagedtogetasked.

3.chiefcomplaintexam(noactivecomplaint)
briefhistory69/M/Mdm,hptmorethan15yrs,gout,IHD6yrs
PEfindingallnormal,exceptlossofvibration(lecturerasktodemonstratehowtocheckperipheral
neuropathy,howtipalpatecardioM,cannotfeel,evenonleftlatposition,sohadtopercusss)
diagnosisdm,hpt,
questionsaskedbylecturerDMHPTCx,causesofblackout(patientclaimedhadMVAd2
blackout),interpretptresult,otherIxbesideblood,howtocalculateotcreatfromage,sideeffectof
drugstatinmyositis,ysodiumlowinthispt(notsurewhichdrugcauseit),whatadviceyouwanna
givetheptregardingthediseasecontroletc,adviceonhowtomakeptcompliancetomeds.

4.chiefcomplaint:noactivecomplains.cameinforexam.
underfollowupatRUKAandO&Gfor:
endometrialCa(postTAHBSO)
asthma
deepveinthrombosis
obesityandDiabetesMellitus
briefhistory
suhaili,35,malay,lady
a)asthma,sincechildhood,wellcontrolled,currentlyonbicotideandventolin
b)dvt,currentlyonwarfarin8mgOD,INR:23,wellcontrolled.had3episodes
c)endoMCa,doneTAHBSO,15roundofchemo,andbrachytherapy.currentlywell,nosignof
mets/recurrence
d)Diabetes:currentlyonmetformin850mg,diamicron1tabletOD,insulatard10Ubeforebed.
PEfinding
leftlegswellingwithvaricosevein
20cmPfannenstielscarpostTAHBSO
diagnosis
uncontrolledDMwithobesity.andcurrentlyonmedicationforDVT
questionsaskedbylecturer
duringPE:pleaseexamineherlowerlimbs.
demonstratehowuconfirmswelling(measurecircumferenceofcalf),whatisthecausesof
unilaterallegswelling,whatcanbethecausesoftheswellinginthispatient(uterinecamets
compressingonlympahticdrainageofleftlowerlimb)
backinroom:howwouldyoumanagethispatientknowingthatshehastheaboveproblems(INR
monitoring,Diabteticcontrolandcomplicationdetection),whatbloodIxwouldyoudoforher?if
HBA1cis11.1whatdoesitmeanandwhatshouldyoudo?
ifprotein1+whatdoesitmeansdoesitmeanshehasdiabeticnephropathy?whataretheother
causes?whatsortofdietregimedoyouknowof?hercurrentBMIis37.7,whatshouldbethe
ideal?(1822.9forasians)

5.Chiefcomplaint
Currently,cameforexampurposed,butpresented15yearsagowithchiefcomplaintofseizuresfor
onedayduration
Briefhistory
44yearsoldMalaygentleman
Hewasapparentlywelluntil15yearsago,whenhefirstdevelopseizureswhilesleeping(around
34aminthemorning)
Upperlimbheldinflexionpostion
Droolingofsaliva
Bittingoftoungue
Uproolingofeyeball
Lastfor510minutes
Noticedbyhiswife
Nothingmuchdonebythewifeasshewaspanicking
Postictalhedevelopshorttermmemoryloss(canotrememberthedate,time,whetherhesworking
ornot)
lastedforonehour
associatedwithdizziness
Forthefirsttime,didnotseekmedicalattentionashetaughtitwasnormal.
Then34monthslater,developsecondepisodewhichwassimilarthefirstonebutstilldidnotseek
formedicaltreatment
Onlyforthethirdtimeheseekformedicalattentionasitwasadvicebyhisuncle
Sowithinoneweek,wenttoHospitalTampinandwasrefertoPPUMforfurtherinvestigations
InPPUM,hewasarrangedforEEGwastoldtheresultwaspositiveandwasstartedontegtigrol
for3monthsandwithdrawbecauseofsideeffect(rashes)
Thenmedicationwaschangetophenytoinuntilnow
Since1997uptonow,hisconditionwasimproving(frequencyofattack12times/year)compared
topreviousone(34timesperyear)andlessbleedingoftonguebitting
ForcomplianceAttendregularfollowup(6monthly),compliancetohismedication,nevermiss
medication
Lastattack6monthsago
Lastfollowuplast2weeks,alsonotedBPhigh(140/90)

SocialhistoryNotaffectinghisjobsordailyactivityasitusuallyoccurduringsleep
Chronicsmokerfor20years
Nohistoryadmissionbecauseofseizure
SytemicreviewNolow,noloa,nofever,nochroniccough,nocontactwithtb,nohemoptysis
Nosymptomsofhypoglycemiabeforeattack
Noearlymorningheadache,nonausea,novomiting,noblurringofvision
Nochestpain,nosob
Noolugouria,nocturia,urinarysymptoms,noalteredinbowelhabit
Nocalfpainduringwalking,intermittentclaudication
NohistoryofMI/TIA/Strokebefore
PEfindings
O/ealert,conscious,responsive
nopedaloedema
Vitalsign
BP140/100
PR80bpmNVRRNoSC
RR20breaths/min
Tfebrile
CNS
Tonenormal
Power5/5
ReflexIntact
SensationIntact
PlantarDowngoing
CVS
Unabletolocatetheapexbeat(huhuhuhu)
S1,S2heard,nomurmur
Lung
Hyperinflatedwithlossofcardiacdullnessandliverdullness
VesicularBS,equalairentry,nocreptsorrhonchi
UrineDipstick
Protenuria+1
Diagnosis
Epilepsywithhypertension
Questionsasked
1.PECommentonperipheralxmNopallor,nojaundice,nocyanosis,hydrationstatusfair

Elicittheupperlimbreflexes(biceps)
DemonstratehowyoucheckforapexbeatasIsaidIwasunabletolocateit
WhydoyouthinkapexisnotpalpableinthispatientBcosimshivering(theyall
laugh..huhuhu),wutelse?
Thickchestwall
Hyperinflatedlung(afterpromptbyexaminerassheask
therelationbetweensmokingandlung
Demonstatehyperinflatedlung
Showmethenormalsiteforapexbeat(pointingat5thleft
ICS)makesureshowthemidclavicularlineandcountthe
intercostalsspacefrom2nd
DidyoucheckforthefundusImsorryIdidnthavemuchtimetodothatbutIwouldliketo
completemy
examinationbycheckingfundusforhypertensiveretinopathy,signofpapillodema
2.Intheroom
a.WhatdoyouthinkthepatienthasEpilepsy
b.Why,giveyourreasonrepeatedepisodehistoryofseizures
c.Howdoyouthinkhesconditionnowwellcontrolledandgettingbetterwithtreatmentas
frequencyreduces(12timesyear)comparedtopreviousoneandcurrentlytonguebittingless
bleeding
d.Isthereanyspecificcausingtheseizuresfromthehistory,Icouldnotfindanyspecificreason
fortheseizurestooccurashehadsymptomsoflow/loa,nofever,nocough,nocontactwithtb,no
hemoptysis,nofamilyhistoryofepilepsy/brainpathology,andonlyoccurwhenhewassleeping
e.Letsaythepatientpresenttoyouforthefirsttime,whatarethethingsushouldconsider
Consideringtheageofpatient&lateonsetofseizures,fewdifferentialdiagnosisthatIshould
consider
i.IntracranialpathologysuchSOLbraintumor
ii.InfectionsMeningitis,encephalitis,TBabscess
iii.MetablicdisturbancesHypo/Hypernatremia,Hypocalcemia,Hypogylcemia
iv.AVM
f.Forthemetaboliccause,whichonethemostimportantcauseofseizuresHypoglycemia(fair
enuf)
g.Letsaythepatienthadbrainpathology,howusuallytheypresentEarlymorningheadache,
nausea,vomiting,signofpapillodema
h.Ifususpectthepatienthattumorinthebrain,whatinvestigationsuwannaorderCTscanof
braintolookforthelesion/mass,location,thesize,shape,infiltrationtosurroundingstructure,
midlineshift,inverventricularextension
i.NowtheEEGshowpatienthadepilepsy,whatisyourfurthermanagement?Listproblemthat

patienthadnow
i.Epilepsywellcontrolled
ii.HighBP
j.Fortheepilepsyputpatientonregularfollowup,makesureheiscompliancetomedication,and
nevermissmedication
k.Howtoaccessptcompliancetomedicationotherthanaskinghim(lostforawhile),whatare
expecttoseeinblood?
ohthelevelofdrugwithinthebloodsystem..huuhuhu
l.Howdoyouadvicepatientforhisepilepsy?Whatistheabsolutecontraindicationforthesports
thehecannotdo?
Avoiddrivingthecar(ifpossibleaskthewifetodrivethecar),certainjobs(lorry,busdriver,use
theheavymachineliketheconstructionsiteshouldbeavoided),foractivity(nocycling,swimming,
suddenlyterkeluarfootball(zzzzz,thenexamineraskwhy?hahahahh)
m.WhataboutthehighBP
Lifestylemodificationsmokingcessation,regularexercise,reduceweight

6.Chiefcomplaint
cameforexam
History
44/m/gentleman,dxwithepilepsyfor14years.nopreviousadmissioninppum,followinruka.last
attackonoct2010duetostoptakingdrugforaweek.GTCduringsleeping,onphenytoinno
complications.noothermedicalillness.stilldriving
PE
nofinding.askedtoshowthesignsoffocallesion(increasedICP):papiloedema,unequalpupils,
visualfield(HHandbitemporalhemianopia),diplopia(LR6).
PhenytoinSE:signsofanaemia,gumhypertrophy.
bp140/100

diagnosisepilepsy
questions:
watpsychologicalillnessassociatedwithchronicdisease?
investigationswhenpatientfollowupinclinic
longtermmanagement?
advicetofamilymemberswhenseizureshappen?
adviceonsmoking?(prof)
drivingissues?
willudiagnosehimhptonsinglereading?

7.chiefcomplaint:recruitedforexambymohazmi
briefhistory:uncontrolledDM,HPT,hyperlipidaemia,BPH.Polioatageof5,complicationOKU,
presentallthensummarize,theyarequitepatientithink.
PEfinding:BedsideexaminationofULinspection,rightside,wastingofthenarmuscle,foream
musclewasting,mediannerveaffected,examineulnarandradialnormal.ThenexamineULmotor,
patientcompensatedtheelbowextensionbyshoulderpushingforward.Thenlowerlimbinspection,
wastingofleftlowerlimb,objectivemeasuringthecircumference,thencheckthevibration(prof
philipaskhowtocheckifpatientREALLYfeelthevibration???cozutouchtheptosonoe,buthe
saidimnotsayingthatthepatientwilltelllies,lateranswillbecomparingwithchest,theques
soundsinterestingbutanswerhewantweird).Fundoscopysilverwiring,pteyesdilatedtopupil
size9mm.Othersbedsideexaminationidourineexaminationalltheydidnotask.
diagnosis:explainaboutthefindings,poliomyelitis,anthorncellthenlowermotorneuron
questionsaskedbylecturer
Askaboutinvestigation....reason
Thenaskaboutsomeissueslikelisinoprilcautionb4giving,renalarterystenosis,ruleoutu/s,renal
bruits.ManagementifpatientstilluncontrolledDM,howtostartinsulin,prebed,dosage.Ptwith

familyhxofcolorectalca,ptcamewhatwillyoutellhim,laterprofaskhowtoscreenhimeasily,
fecaloccultblood.Thesideeffectofthedrugs,metformin,gliclazide,lisinopril.Lastquesifpt
cannottoleratelisinopril,presentwithcough,whatwillyoudo,changeACEtoARB,thenprofask
whatisARB???

8.chiefcomplaint:
Noc/ola,comeforexam...huhu..historyofdmnhptfor16yearsanddyslipidaemiafor8years.
briefhistory
DMcontrolnotsogoodevencompliancetomedication.HPTreadingisgood.LDLandHDLnot
innormalrange.educatedperson(anaddmathteacher)andverynice.dietnotreallycontroln
exerciseless.hootherDMcxlikeIHDordiabeticnephropathy.previouseyecheckupshows
peripheralhemorrange.disptgotEDandonviagra.
PEfinding
AllnormalexceptpresenceofskinlesioninDMandI'mnotsureabouttheskinlesionsobetter
knowinandoutboutDMk.
diagnosis
DMnHPTwithdyslipidaemiawithnosymptomsofhyperglycaemia.
questionsaskedbylecturer
Dietfordiabeticpatient.
HowdoumanageptwithHBA1c>8?
TargetHBA1cfordispt?
Bedside:performperipheralneuropathyexaminationandpalpatepulses.
Ixfordispt
sideeffectARBandwhenucannotuseARB?