Saturday, March 24, 2018
A 22-year-old man presented with malaise and anorexia for 1 week. He vomited on one occasion, with no blood. He has felt feverish but has not taken his temperature. For 2 weeks he has had aching pains in the knees, elbows and wrists without any obvious swelling of the joints.
He has not noticed any change in his urine or bowels.
Five years ago he had glandular fever confirmed serologically. He smokes 25 cigarettes per day and drinks 20–40 units of alcohol per week. He has taken marijuana and ecstasy occasionally over the past 2 years and various tablets and mixtures at clubs without being sure of the constituents. He denies any intravenous drug use. He has had irregular homosexual contacts but says that he has always used protection. He claims to have had an HIV test that was negative 6 months earlier. He has not traveled abroad in the last 2 years.
He is unemployed and lives in a flat with three other people. There is no relevant family history.
He has a temperature of 38.6°C and looks unwell. He looks as if he may be a little jaundiced. He is a little tender in the right upper quadrant of the abdomen. There are no abnormalities to find on examination of the joints or in any other system.
(normal values shown in brackets)
Haemoglobin 14.1 g/dL (13.3–17.7 g/dL)
Mean corpuscular volume (MCV) 85 fL (80–99 fL)
White cell count 11.5 × 109/L (3.9–10.6 × 109/L)
Platelets 286 × 109/L (150–440 × 109/L)
Prothrombin time 17 s (10–14 s)
Sodium 135 mmol/L (135–145 mmol/L)
Potassium 3.5 mmol/L (3.5–5.0 mmol/L)
Urea 3.2 mmol/L (2.5–6.7 mmol/L)
Creatinine 64 μmol/L (70–120 μmol/L)
Bilirubin 50 mmol/L (3–17 mmol/L)
Alkaline phosphatase 376 IU/L (30–300 IU/L)
Alanine aminotransferase 570 IU/L (5–35 IU/L)
Fasting glucose 4.1 mmol/L (4.0–6.0 mmol/L)
• What is your interpretation of the findings?
• What is the likely diagnosis?
• What treatment is required?
Answers And Discussion
Tuesday, January 9, 2018
A middle aged man has developed numbness and tingling in his toes and feet, and more recently his fingertips. He also complains that he trips up more frequently.
Clinical Approach: This man has distal sensory symptoms and motor symptoms. Here it is important to decide whether this is due to a peripheral cause , central or a combination of both.
Clinical History :
1. Is this an urgent case? Ask about the duration of symptoms and rate of progression. Any worrying associated symptoms like loss of sphincter control or difficulty in breathing.
2. Differentiating between peripheral and central nervous system dysfunction:
A peripheral nervous system dysfunction is characterized by
- tingling, numbness and burning in feet.
- Numb fingers.
- Foot drop
- Difficulty in rising from a chair
- Difficulty in going up and down stairs.
A spinal cord lesion is characterized by
- Legs and feet feeling stiff and heavy.
- Clumsy stiff hands
- Sphincter disturbances.
3. Duration of symptoms may help determine the cause of neuropathy.
4. Any associated pain.
Past History: Ask specifically about:
- Diabetes mellitus
- Alcohol intake
- Current medications
- Dietary history
- Pernicious anemia
- Weight loss
- Neck trauma
- Rheumatoid arthritis.
1. Signs in case of peripheral nervous system disorder
- Distal weakness
- Absent ankle reflexes
- Stocking distribution sensory loss
- Muscle wasting (if severe)
2. Signs in case of central nervous system disorder
- Spastic tone
- Weakness both proximal and dismally, but predominantly in leg flexor
- Brisk reflexes
- Extensor plantars
- Possible sensory level
3. Is is important to check if the signs are symmetrical?
- Asymmetry in the context of an upper motor neurone syndrome would represent a Brown-Sequard syndrome with loss of proprioception ispilateral to the weak leg, and loss of pain and temperature sensation contralateral to the weak leg.
- Asymmetric lower motor neurone findings suggest mononeuritis multiplex or entrapment neuropathic..
4. Check for associated cranial nerve pansies
- Deafness in CN VIII
- Bilateral facial weakness in Guillain-Barre syndrome and Sarcoidosis
- Malignant infiltration of the basal meninges may lead to multiple cranial nerve palsies.
5. General Examination :
Look and check if the patient is systemically well?
- Cachexia may suggest malignancy or alcoholism
- Vasculitic rash in systemic vasculitis
- Look for signs of hypothyroidism
Monday, November 27, 2017
A 45 years old man consults his general practitioner (GP) with a 6-month history of reduced appetite
and a weight loss, from 78 to 71 kg. During the last 3 months he has had intermittent nausea, especially in the mornings, and in the last 3 months the morning nausea has been accompanied by vomiting on several occasions. For 1 month he has noted swelling of his ankles. Despite his weight loss he has recently noticed his trousers getting tighter. He has had no abdominal pain. He has no relevant past history and knows no family history as he was adopted.
He takes no medication. From the age of 18 he has smoked 5–6 cigarettes daily and drunk 15–20 units of alcohol per week. He has been a chef all his working life, without exception in fashionable restaurants. He now lives alone as his wife left him 1 year ago.
He has plethoric features. There is pitting oedema of his ankles. He appears to have lost weight from his limbs, but not his trunk. He has nine spider naevi on his upper trunk.
His pulse is normal, and the rate is 92/min. His jugular venous pressure (JVP) is not raised, and his blood pressure is 146/84 mmHg.
The cardiovascular and respiratory systems are normal.
The abdomen is distended. He has no palpable masses, but there is shifting dullness and a fluid thrill
Haemoglobin = 12.6 g/dL (normal = 13.3–17.7 g/dL)
White cell count = 10.2 × 109/L (normal = 3.9–10.6 × 109/L)
Platelets = 121 × 109/L (normal = 150–440 × 109/L)
Sodium = 131 mmol/L (normal = 135–145 mmol/L)
Potassium = 4.2 mmol/L(normal = 3.5–5.0 mmol/L)
Urea = 2.2 mmol/L (normal = 2.5–6.7 mmol/L)
Creatinine = 101 μmol/L (normal = 70–120 μmol/L)
Total protein = 48 g/L (normal = 60–80 g/L)
Albumin = 26 g/L (normal = 35–50 g/L)
Bilirubin = 25 mmol/L (normal = 3–17 mmol/L)
Alanine transaminase = 276 IU/L (normal = 5–35 IU/L)
Gamma-glutamyl transaminase = 873 IU/L (normal = 11–51 IU/L)
Alkaline phosphatase = 351 IU/L (normal = 30–300 IU/L)
International normalised ratio (INR) = 1.4 (normal = 0.9–1.2)
Urinalysis: no protein; no blood
• What is the diagnosis?
• How would you manage this patient?
Thursday, September 28, 2017
A 23-year-old man presents following a fall onto his left shoulder whilst playing rugby. He complains of pain throughout the shoulder and on examination has weakness when testing internal rotation of the arm compared to the contralateral side.
Radiographs are negative.
Injury to which tendon would explain his symptoms?
E Teres minor
A first-time mother brings in her 5-day-old baby for a well-child visit. The nurse weighs the infant and reports a weight of 7 lb 5 oz to the mother. The mother looks concerned and tells the nurse that her baby weighed 7 lb 10 oz when she was discharged 4 days ago.
The nurse’s best response to the mother is:
A. “I will let the doctor know, and he will talk with you about possible causes of your infant’s weight loss.”
B. “A weight loss of a few ounces is common among newborns, especially for breastfeeding mothers.”
C. “I can tell you are a first-time mother. Don’t worry; we will find out why she is losing weight.”
D. “Maybe she isn’t getting enough milk. How often are you breastfeeding her?”
Wednesday, September 27, 2017
A 40-year-old school teacher develops nausea and vomiting at the beginning of the fall semester. Over the summer she had taught preschool children in a small town in Mexico. She is sexually active, but has not used intravenous drugs and has not received blood products.
Physical examination reveals scleral icterus, right upper quadrant tenderness, and a palpable liver. Liver function tests show aspartate aminotransferase of 750 U/L (normal < 40) and alanineaminotransferase of 1020 U/L (normal < 45). The bilirubin is 13 mg/dL (normal < 1.4) and the alkaline phosphatase is normal.
What further diagnostic test is most likely to be helpful?
a. Liver biopsy
b. Abdominal ultrasound
c. IgM antibody to hepatitis A
d. Antibody to hepatitis B surface antigen
e. Determination of hepatitis C RNA