case study

A 64 year old male with previous history of hepatitis B infection presented with gastrointestinal bleeding. On examination, he was pale and jaudiced and presence of palmar erythema, spider naevi and hepatosplenomegaly.

Investigation results are as follows

Hb 6.2 g/dl
WBC 3.6 X 10⁹/l
neutrophils 1.8 X 10⁹/l
lymphocytes 1.2 X 10⁹/l
platelet 98 X 10⁹/l
PT 20s(normal 12-14s)
APTT 46s(normal 26-33.5s)

Question:

1. Discuss the lab results

pancytopenia

• anaemia (indicated by low Hb level)

• leukopenia (indicated by low WBC count)

• thrombocytopenia ( indicated by low platelet count)

coagulopathy

• impaired extrinsic pathway (prolonged PT)

• impaired intrinsic pathway (prolonged APTT)

2. What are further investigations would you consider in this patient

- Liver function test- to look for evidence of liver failure
- OGDS (oesophago-gastric-duodeno-scopy) - to look for esophageal varices and any other GI bleeding
- stool occult blood - to look for evidence of lower GI bleeding

3. What is the most likely diagnosis

Chronic liver failure

( Chronic Hepatitis B infection cause chronic liver failure in this patient results in cirrhosis of liver parenchyma. Cirrhosis cause portal hypertension leads to esophageal varices and so leads to GI bleeding. Chronic loss of blood leads to anaemia. Cirrhosis also leads to spleen enlargement as a result of portal hypertension. Sequestration of blood cells occur leads to pancytopenia and further aggeravates the bleeding)

4. How would you manage this patient

Resuscitation
- Stop the bleeding
- Transfusion of blood product (fresh frozen plasma)

Limb Weakness

A 20 year old man come with 5 days of lower limb weakness. It was preceded by fever and sore throat. He had difficulty in walking, calf pain and tingling sensations in toes and fingers. Later, the weakness extended to his arm.

Physical examination revealed wide based gait, decrease in muscle strength in all extremities and absent of deep tendon reflexes in leg. All cranial nerve is intact. There is no papilloedema.

1. State the most likely diagnosis for this patient (2marks)

2. Briefly describe the pathogenesis of this patient condition. (3marks)

3. State 2 characteristic feature of weakness seen in this patient that support your diagnosis. (3marks)

4. State one complication that might happen in this patient. (1mark)

Stroke

A 65 year old man suddenly collapsed. He was unarousable except for painful stimuli and did not move his right limb at all. He had hypertension but poor compliance to medication. His mother passed away because of complication of hypertension.

On examination, he is obese. Blood pressure is 260/140 mmHg. There is no neck stiffness. There was no speech and did not respond to verbal stimuli. His right limb did not move even with painful stimuli. There were present of hyperreflexia and hypertonia of extensor right upper and lower limb. There were present of plantar response. There was no papilloedema.

1. Interprete the neurological findings in this patient (2marks)

2. State the most likely diagnosis and site of lesion in this patient. (2marks)

3. List 4 risk factor for the presenting features in this patient (4marks)

4. Briefly describe the pathogenesis of the presenting features in this patient (3marks)

5. Relate his clinical condition and his speech abnormality (2marks)

amenorrhea,hirsutism,obesity

A 32 year old female came with amenorrhea , hirsutism (facial hair) and obesity

a.Give two causes of above complaints.

• Increase cortisol in blood (hypercortisolism)
• Increase prolactin in blood (hyperprolactinemia)

b. State 3 investigation that you would like to do and give reason

• Dexamethasone suppression test

To check the cause of high cortisol , weather it is ACTH dependent or not.

• Skull x-ray

Can visualize if there is pituitary gland adenoma

• Blood test to measure prolaction and cortisol level in blood

High cortisol and prolactin will give rise to above symptoms

On physical examination

Pulse rate : 80 beats/min

Blood Pressure : 150/90 mmHg

There is echymosis.

Dexamethasone test also done.

c.Principal of dexamethasone test

• It has two types, low dose and high dose. Patient will be inject with exogenous steroid (dexamethasone), in low dose-1-2mg and hig dose-8mg. To get the result cortisol level will be measured. A normal result is decrease in cortisol levels upon administration of low-dose dexamethasone.

d.Give the diagnosis

• Pituitary adenoma (which secrete ACTH and Prolactin)

e. Explain pathophysiology of each sign and symptoms in this patient

• hyperprolactinemia-Inhibit effect of gonadotrophin releasing hormone (GnRH) on sex organ-No LH and no FSH-no ovulation and follicular development-amenorrhea
• hypercosticolism-increase fat metabolism-fat redistribution-fat deposited on face , trunk and at the back-obesity
• hypercorticolism-reduce fibroblast activity and collagen synthesis-thin skin-easily bruise-ecchymosis

Extra:

1.In Cushing dz, no change in cortisol on low-dose dexamethasone, but inhibition of cortisol on high-dose dexamethasone. If the cortisol levels are unchanged by low- and high-dose dexamethasone then other causes of Cushing's Syndrome must be considered. In ectopic ACTH secretion (paraneoplastic syndrome), ACTH level will be high even in high dose of dexamethasone.

2.Normally prolactin is inhibited by PIF (dopamine secreted by hypothalamus).

3.Physiologically high prolactin occur in lactation which also will cause amenorrhea.

~living well or living hell? Fighting for future!~

mari meneka.. :)

10 tahun, laki, tak leh gerakkan kaki dan berdiri sejak 2 hari yang lalu.... sebelom nie, die ade history pernah jatuh banyk kali bile berjalan dan cepat letih. tak boleh berlari, melompat dan berjlan laju.. bahagian atas ok la..boleh gerak tangan lagi.. bile di ajar lambat pickup. selalu dapat chest infection. mak ayah sihat je... tp pak cik belah mak pakai kerusi roda sejak umor 12 tahun....

a) DIAGNOSIS?
b) INVESTIGATION?
c) COMPLICATION?

Acute abdomen with shock

A 69 years old hypertensive female was brought to A&E department for having an acute abdominal pain after lifting her furniture. She describes her pain as sharp and radiate to the back. On quick assessment, her abdomen is found to be distended and tender; her pulse is 120 beats per minute and weak and her BP is 70/68. However, the patient suddenly collapse and she dies after the resuscitation fail. Post Mortem revealed a ruptured abdominal aorta.

1) Based on history, state 2 predisposing factors and 1 precipitating factor in this patient (3m)

2) Explain the Pathophysiology of ruptured abdominal aorta in this patient (4m)

3) Explain the mechanism causing the low BP and high but weak pulse. (3m)

Answer at the bottom of the post. Do it on your own first please!!

Kenapa saya sayang PBL saye? Sebab ia BEST!!

Answer:

1)

a) Predisposing factor

- Age > 65 years old

- Hypertension

b) Precipitating factor

-Increase abdominal pain after lifting up the furniture.

2) Pathophysiology

Atherosclerosis à Narrowing of the abdominal aorta lumina à Weakening of intima layer and separation of its layer à blood filled the cavity and for hematoma. à Hypertension worsening the hematoma à Aorta dilatation and aneurysm formationàIncrease in abdominal pressure trigger the rupture of abdominal aorta

3) Mechanism of compensation

Bleedingà low blood pressure à reduce the aortic and carotid baroreceptor firingà reduce the inhibition to the medulla à activation of the sympathetic system and releasing of adrenaline à Increase heart rate à Increase in pulse rate. However, continuous loss of blood cause the pulse to be weak due to lack of volume.

Cyanotic infant with shortness of breath

A 5 months old boy was brought to the hospital because of difficulty in breathing. There is bluish discoloration of skin. He appears small compare to other infants at his age.

1) Label the abnormalities observed in 1-4 (4m)

2) What is the name of the disease (1m)

3) List three predisposing factor for the cause of disease(3m)

4) Outline 2 treatment for this baby (2m)

5) What cause the small size baby and the bluish discoloration (4m)

Answer is in the comment. But please answer on your own first before looking at the scheme.