SECTION 2 LOOK AND PROCEED: SPOT DIAGNOSIS A.

Face Systematically run through your mind if the patient has one of the following facies: Abnormal habitus: Marfans, Gigantism, Turners syndrome, Osteogenesis imperfecta. Endocrine facies: Acromegaly, Cushingoid, Hypothyroidism, Hyperthyroidism Syndromic facies: Down syndrome, Turners syndrome. Neurocutaneous syndrome: NF-1, Sturge Weber syndrome, Tuberous sclerosis. Myopathic facies: Myotonic dystrophy, Myasthenia gravis, CPEO, Fascioscapular-humeral dystrophy. f. Connective tissue disease: SLE, Scleroderma, Dermatomyositis. g. Skin lesions: Acne, Malar rash, Discoid rash, Adenoma sebaceum, Rhinophyma, Lupus pernio (sarcoidosis), Depressed nasal bridge (Syphilis, Wegeners granulomatosis, relapsing polychondritis). B. Hand Common Hand Cases: a. Abnormal finger length: arachnodactyly, pseudohypoparathyroidism (short fourth metacarpal). b. Nail changes: clubbing, leukonychia, splinter haemorrhages, yellow nail syndrome, Mees line (arsenic poisoning). c. Rheumatological causes with Bony deformities/skin changes: RA, OA, gout, sclerodactyly, Raynauds phenomenon, Gottrons papule. d. Neurological causes of wasting: claw hand (unilateral, bilateral). C. Legs Abnormal postures/ shape Varus or valgus deformities, scars (knee replacement, traumatic) Genu varus (Osteoarthritis, Pagets) Genu valgus (Rickets) Necrobiosis lipiodica (DM) Pretibial myxoedema (hyperthyroidism) Erythema nodosum (TB, sarcoidosis, streptococcal infection, inflammatory bowel disease) Pyoderma gangrenosum (inflammatory bowel disease) Purpura (Henoch schonlein purpura, thrombocytopenia, Neisseria) DVT (Homans sign positive) Varicose veins Pitting oedema (CCF, chronic liver disease, nephrotic syndrome) Non pitting oedema (elephantiasis/filariasis) Foot drop, pes cavus, clawing of toes inverted champagne bottle (CMT) a. b. c. d. e.

Skin lesions

Cellulitis DVT Venous ulcers Swelling (pitting & non Pitting) Wasting

Nose a. Saddle nose secondary to - syphilis - Wegeners granulomatosis, - yaws - recurrent perichondritis b. Lupus pernio

Eye a. Pterygium b. Kaysier Fleischer ring c. Iris nodule Brushfield d. Spot in Downs syndrome

Head and Face a. Alopecia b. Loss of lat 1/3 of eye brow (hypothyroidism) c. Xanthelasma d. Heliotrope rash e. Angioedema f. Acne vulgaris g. Adenoma sebaceum Oral cavity Perioral dermatitis b. Atrophic glossitis c. Beefy red tongue d. Aphthous ulcer e. Mucositis secondary to Methotrexate or StevensJohnson syndrome f. Tonsillitis g. Peritonsillar abscess (quincy) Trunk a. Tattoo b. Photosensitivity mark c. Spider naevi d. Gynaecomastia Elbow a. Cubitus valgus b. cubitus varus c. IVDU venepuncture marks d. Patergy sign (Behcets) Legs a. Genu varus (Osteoarthritis, Pagets) b. Genu valgus (Rickets) c. Necrobiosis lipiodica (DM) d. Pretibial myxoedema (hypothyroidism) e. Erythema nodosum (TB, sarcoidosis, streptococcal infection, inflammatory bowel disease) f. Pyoderma gangrenosum g. Cellulitis +/- DVT h. Venous ulcers i. Varicose vein, venous flare j. Purpura

Ear a. Gouty tophi b. Caulli flower ear c. Pinna haematoma d. Ochronosis (Alcaptouria)

Neck a. Short, webbed neck b. Goiter c. Lingual thyroid

Upper limb a.Shoulder subluxation b. Ruptured bicep tendon Abdomen a. Renal Transplant scar b. Sister Josephs nodule c. Ascites d. Gray Turners sign (due to retroperitoneal haemorrhage) Hand a. Rheumatological causes with Bony deformities/skin changes: RA, OA, gout, sclerodactyly, Raynauds phenomenon, Gottrons papule b. Abnormal finger length: arachnodactyly, pseudohypoparathyroidism (short fourth metacarpal) c. Nail changes: clubbing, leukonychia, splinter haemorrhages, yellow nail syndrome, Mees line (arsenic poisoning) d. Neurological causes of wasting: claw hand (unilateral, bilateral)

Buttock a. Tuberoeruptive xanthoma b. Cutanous larva migrans

CLUES TO DIAGNOSIS: Diagnosis Hand Findings Other Associated Clinical Features

Rheumatological conditions: Rheumatoid Arthritis Ulnar deviation, Z deformity (thumb), mallet finger (swan neck deformity), bouttonierre deformity, symmetric MCP & PIP swelling and tenderness, subluxation. Dorsal guttering (disuse wasting of intrinsic muscles). Psoriatic arthritis Nail pitting, onycholysis, DIP swelling and tenderness. Psoriatic plaque over scalp, retroaural region, extensor surface, trunk (periumbilical), buttock, Koebners phenomenon. OA of knee, knee varus deformities. Bird-like facies (pinced nose, microstomia) pulmonary fibrosis, oesophageal dysmotility. Heliotrope rash over face. Cushingoid, pallor, Rheumatoid nodule Knee joint replacement scar. Scars on the hand: dorsum (tendon repair); palmar wrist (carpal tunnel release)

Osteoarthritis

Heberdens node (DIP), Bouchard nodes (PIP). Sclerodactyly, CREST syndrome (Calcinosis, Raynauds phenomenon, Telangiectasia). Gottrons papule.

Scleroderma

Dermatomyositis Neurological conditions: Unilateral hand wasting: a. Brachial plexopathy secondary to Pancoasts syndrome

Clubbing, wasting of intrinsic muscles, nicotine stain.

Horners syndrome, trachea deviation, rib tenderness. Rib tenderness.

b. Cervical rib

Reduced sensation/ paresthesia over C8/T1. Scar over neck.

c. Post traumatic brachial plexopathy

10

Diagnosis

Hand Findings

Other Associated Clinical Features Hansens disease thickened nerve, hypopigmented macule with hypoesthesia Post traumatic/plating scar over forearm.

Median or ulnar neuropathy (post traumatic, Hansens)

Carpal tunnel syndrome (thenar wasting, reduced sensation over palmar surface of thumb & 1st, 2nd finger).

Bilateral hand wasting: I) Motor neuron disease

Intact sensory with wasting of intrinsic muscles of hand (apes hand).

Tongue fasciculations, brisk jaw and knee jerk ALS (mixed UMN & LMN signs).

II) Syringomyelia

Dissociated sensory loss scars. Pes cavus, clawing of toes.

III) Peripheral neuropathy (eg. Charcot Marie Tooth)

11

TIPS ON APPROACH TO CUSHING SYNDROME: Examine to look for the underlying cause eg. exogenous steroid ingestion for SLE, rheumatoid arthritis etc. Rehearse in your mind how you will approach a Cushingois patient who has clubbing, cushingoid with abdominal scar (inflammatory bowel disease), cushing with arteriovenous fistula or rectal fistula etc (inflammatory bowel disease).

Figure 2i

Figure 2j

Figure 2k

Figure 2l

Figure 2i: Hirsuitsm and bruises in a rheumatoid arthritis patient on long term steroid. Midline laparotomy scar (Figure 2j) and clubbing (Figure2k & 2l) in a patient with Chrohns disease on long term steroid complicated by upper gastrointestinal bleeding.

17

Respiratory system A - Inspection B - Palpation C - Percussion D - Auscultation Look for signs of Respiratory Distress

Asthma
Look for warning sign of status asthmaticus, atopic eczema, tremor

COPD
Look for signs of superimposed pneumonia, lung CA

Bronchiectasis
Underlying dextrocardia, situs inversus

Fibrosis
Underlying cause e.g. RA, scleroderma, CTD

Pleural
Look for underlying causes of CCF; CTD; nephritis underlying lung Ca, breast Ca

Bronchogenic Ca
Horners syndrome, SVC obstruction, paranoeplastic syndrome

Investigation:
PEFR Skin precipitin test CXR for bullae, consolidation, collapse

Investigation:
CXR for bullae, collapse, consolidation PEFR alpha 1 antitrypsin

Investigation:
CXR for cystic lesion, dextrocardia FBC Sputum C&S/AFB CT thorax (pulmonary aspergillosis)

Investigation:
HRCT Spirometry for Bronchoscopy & BAL Transbronchial lung biopsy CTD screening

Investigation:
Pleural fluid aspirate for FEME, LDH, cytology Pleural biopsy

Investigation:
CXR to look for rib erosion, tracheal deviation, cannon ball opacity CT thorax for mediastinal lymph nodes CT brain, abd for staging

Management:
Bronchodilat or Antibiotics Asthma Action Plan

Management:
Bronchodilator Antibiotics 2 agonist (MDI/Neb) Steroid

Management:
Antibiotics drainage

Management:
Corticosteroid Immunosuppre ssive agent (Azathioprine, cyclophospham ide, cyclosporine) Oxygen Diuretics if cor pulmonale Lung transplant

Management:
Pleural aspiration Chest tube insertion Pleurodesis a. Chemical: talc, Doxycycline b. Surgical

Management:
NSCLC/SCLC - Surgery - Chemotherapy - Radiotherapy

48

QUIZ - RESPIRATORY SYSTEM Describe the abnormalities seen. Systematically run through your mind how you will approach the patient. Rehearse how you will present your findings, diagnosis and differential diagnoses. Answers will be in the following pages.

Figure 3.1

Figure 3.2

Figure 3.3

Figure 3.4

Figure 3.5

Figure 3.6

49

SECTION 7 HISTORY TAKING

Tips on history taking Cardiovascular System (CVS) a. Chest Pain b. Breathlessness/shortness of breath c. Palpitation d. Infective Endocarditis Respiratory System a. Cough b. Hemoptysis Gastrointestinal (GIT) a. Jaundice b. Abdominal pain c. Chronic diarrhoea d. Pedal oedema Neurology a. Headache b. Syncope c. Fits d. Young stroke e. Weakess of hands or legs Haematology a. Anaemia b. Bleeding tendency Infectious disease (ID) a. Pyrexia of unknown origin (PUO) Rheumatology a. Joint pain b. RA c. SLE Genitourinary system (GUS) a. Proteinuria (Nephrotic) b. Haematuria c. Acute renal failure d. Chronic renal failure

149 153, 156 153, 161 165 153 154, 167 154, 170 154, 173 176 154, 180 184 188 155, 194 155, 198 154 204 208 209 210 211 212 213 214 215 216 217

148

SECTION 7 TIPS ON HISTORY TAKING: 1. The cases for history taking can be divided into two main groups: a. Cases with diagnostic problems (eg. pyrexia of unknown origin/PUO, chronic diarrhoea, syncope) b. Cases with management problems (chronic diseases eg. rheumatoid arthritis, SLE, recurrent stroke multiple sclerosis with physical disability). The approach varies in that for cases with diagnostic problem, it is crucial to include a lot of relevant negatives to let the examiner know that youve tried to exclude most of the differential diagnoses. For examples in PUO, it is important to include relevant negatives like no history of travel to jungle, insect bite, recent instrumentation. No joint pain and malar rash. No recent weight loss. For cases with management problems, especially those chronic diseases, it is important to include details of: a. Impact of the illness to the patient & family, how the patient perceives the illness and how he/she is coping with the disability. b. Psychosocial aspect i. Any symptoms of depression ii. Financial aspect iii. Religion & spirituality In all cases, try to get the details of 3C during history taking: a. Cause b. Condition - severity c. Complications - secondary to the illness as well as secondary to the treatment For each symptoms eg. chest pain, further evaluate the: a. Site b. Radiation c. Nature d. Severity e. Associated symptoms f. Onset, duration g. Precipitating factors h. Relieving factors For neurological symptoms, the chronological order of each symptoms onset, whether acute, sub-acute or chronic are important to determine the underlying aetiology of the illness. The underlying cause can be classified as below: Aetiology C - Congenital T - Trauma I - Inflammatory I - Infective V - Vasculitis M- Metabolic N - Nutritional N - Neoplastic D - Degenerative I - Iatrogenic P - Psychogenic Examples Congenital malformation, Arachnoid cyst Head injury with brachial plexus/ root avulsion Acute disseminated encephalomyelitis (ADEM) HIV, syphilis, tuberculosis (TB), cryptococcal SLE, Wegeners granulomatosis Alcohol, toxic encephalopathy/neuropathy eg lead encephalopathy and neuropathy B12 deficiency Lymphoma, leukaemia, paraneoplastic syndrome Cervical spondylosis, dementia Drug induced Parkinsonism Pseudoseizure

2.

3.

4.

5.

6. 7.

149

Approach to Chest pain

Cardiovascular

Respiratory

Gastrointestinal

Musculoskeletal

Ischaemic heart disease (IHD) Angina (stable/ unstable angina) AMI (STEMI/ NSTEMI)
160 Investigation: Investigation: ECG Cardiac enzymes Troponin Test

Dissecting Aortic Aneurysm

Pleuritic pain

Pulmonary embolism

Reflux oesophagitis

Costochondritis

Investigation: Echo CT angiogram (CTA) Management: Control hypertension Surgery if involves proximal aorta

Investigation: ECG CXR

Investigation: D-Dimer Spiral CT thorax

Investigation: OGDS

Investigation: ECG

Management: STK (STEMI) UH (STEMI) SC Clexane (UA) Risk factor modifications

Management: Treat pneumonia NSAIDS

Management: Streptokinase (STK), rtPA Thrombectomy IV Heparin

Management: Proton pump inhibitor (PPI)

Management: NSAIDS

BREATHLESSNESS 1. Differential Diagnoses - CCF - COAD - Asthma - Recurrent Pulm. Embolism - Pleural Effusion - TB - Chronic Lung Disease: Bronchiectasis - Malignancy - Anxiety, Panic attacks - Anaemia HOPC - Signs & symptoms: S.O.B (onset, duration?) Association a. Orthopnea, PND, Pedal edema b. Chest pain c. Wheezing d. Cough: - Productive vs Dry - Sputum: green vs haemoptysis e. GI symptoms: Epigastric pain, etc f. Menopausal symptom g. Hypochondriac symptom Aggravating factors a. Exertion b. Food c. Smoke/dust d. Work Relieving factors a. Prop up b. Rest c. Medication: GTN, -2 agonist inhalers. Diagnosis of problem - Any doctors treated you for similar complaints before? - Complication of problem & previous treatment? - Functional status now and comparison with before? - Progression Medications a. What has been prescribed? b. Any relief? c. Side effects of treatment. d. OCP. e. Precipitant of illness - NSAIDS - worsening anaemia.

2.

3.

4.

5.

6.

7.

161

TIPS ON DEALING WITH UPSET PATIENT/RELATIVE 1 2 Stages and Objectives Introduce yourself Explain role Explore First try to understand why the patient is upset Examples I am Dr Eow, the consultant in charge of the ward. Upset is usually due to the expectations not met or personal rules violated. If the patients expectation is unrealistic, we will point out to the patient in a tactful way. (For example, the son of a patient on methadone replacement therapy is shouting away in the ward, demanding us to treat his father. I told him that we would treat his father, but he has to respect us and not continue shouting at us.) (Explain this part well to show the relative that we have done the best for his/her mom). Your mom is very ill. We have given expensive and good antibiotic; e.g. we have upgraded the antibiotic to a better one from Augmentin to Imipenam. We have also given fluids through the line, running in medications to maintain the blood pressure and having our nurse to monitor the vital signs and condition continuously. We have referred your mom to the intensivist and the respiratory consultant. Your mom will benefit from intensive care monitoring. Unfortunately, there is no ICU bed at the moment. We understand your feelings. We are aware of your frustration. Sometimes, things may not happen as we wish. Complications do occur. For the ICH patient with intraventricular bleed, we let the relative know that we understand they are stress up with seeing the father suffering, understand they have been sleepless taking care of father at night in the hospital. I am sure I would feel the same if I were in your shoes. What is your concern? We understand your concern and we will look into it. We will see what we can do to minimise the sufferings. I am sorry. I apologised on behalf of my junior doctor. I apologise on behalf of my team for whatever shortcomings that had occured. We promise we will do our best to avoid similar condition from occuring.

Explain Explain the current condition; what has been done

Express sympathy

Address concern

Reduce anger Apologise on behalf Remedial action/corrective measure Find out what can be done/ improve the situation.

230

COMPLICATION OF PROCEDURE Mr. Mogan, 70 year-old man with recurrent chest infection. He underwent bronchoscopy. Unfortunatedly he desaturated during the procedure. A. Despite resuscitation, he passed away. Or B. He was successfully resuscitated, now ventilated in ICU. Break bad news to the son. Subheadings Introduction Examples Good morning Mr A, Im Dr. Lim, SHO who is taking care of your father. Thank you for coming! Would you like anyone else to be present during our conversation? Before I go on, may I ask what you have been told regarding your fathers condition? Would you like to know more about your illness? Your dad had recurrent infection to the lungs and we were interested to know what it was due to. A scope inserted through the throat into the lungs was necessary to find out the reason. We asked permission from your father regarding this and after he consented, we proceeded. Why was I not told? (son asked) Im sorry that you were not told regarding this. Im afraid Ive got some bad news to share with youpause During the scope, the scope accidentally torn the wall of your dads throat and caused his heart to stop beating. During that time, we tried to revive your dad by CPR, pumping the heart. However despite all our effort, it was not successful. Yes, Im afraid your dad has passed away. Im sure this must be difficult for you. Offer tissue Would you like to have a drink? Are you ok? Would you like me to leave you alone for some time at this moment?

2 3

Assess understanding Explain what has happened Provide more information/

4 5

Give a warning shot Break bad news

Express sympathy

Dealing with anger

Im sorry this has happened! The person who did the scope was a consultant, an experienced person and this is a very rare occasion by which this complication has occurred.

231

SECTION 9 DERMATOLOGY

Common dermatology conditions Blistering lesions Psoriasis Cutaneous malignancies Cutaneous manifestations of systemic diseases Cutaneous manifestations of systemic malignancies Quiz - Dermatology Quiz - Dermatology (More photos)

249 250 253 255 257 259 261 271

248

SECTION 9 DERMATOLOGY No 1. Dermatology Conditions Maculopapular rash Examples - Drug reactions - Viral exanthem Commonly asked Question What are the possible causes of maculopapular rash in this patient? Differential diagnoses Table to differentiate different lesions Differential diagnosis Table to differentiate different lesions

2.

Vesicular/pustular skin lesions

Chicken pox HSV Kaposi varicelliform Pustular acne

3.

Blistering lesions

- Pemphigus - Pemphigoid - Dermatitis herpetiformis

4.

Flexor surface: Atopic dermatitis Papulosquamous disorders - Lichen planus - Psoriasis (Extensor surface) - Freckles - Chloasma - Melanoma - Squamous cell Ca - Basal cell Ca Carcinoid syndrome Dermatomyositis Acanthosis nigricans Icthyosis Necrotic migratory erythema Thrombophlebitis migrans Melanoma-ABCD

5.

6.

Disorders of Pigmentation

7.

Cutaneous malignancies

8.

Cutaneous manifestations of systemic malignancies

9.

Cutaneous manifestations of systemic diseases (vasculitis) Raynauds phenomena Erythema nodosum Pyoderma gangrenosum

- SLE, discoid lupus - Scleroderma - Henoch Scholein Purpura (HSP) - Sarcoidosis - DM dermopathy - Staphylococcal scalded skin syndrome (SSS) - Impetigo - Tinea - Lymes disease - Cutaneous TB - Cutaneous larva migrans

10.

Cutaneous infection

249

Blistering Lesions

Figure 9a: Pemphigus vulgaris

Figure 9b: Pemphigus vulgaris

Figure 9c: Pemphigus vulgaris

Figure 9d: Pemphigus folliaceus

250

Figure 9e: Bullous pemphigoid

Figure 9f: Bullous pemphigoid

Figure 9g: Dermatitis herpetiformis

Figure 9h: Dermatitis herpetiformis

251

Causes of common fundoscopic findings: Papilloedema Increased ICP (SOL, tumour, abscess, Cryptococcal meningitis, TB meningitis, obstructive hydrocephalus Grade IV HPT retinopathy Idiopathic intracranial HPT (IIH, BIH, pseudotumour cerebri) CRAO/BRAO: HPT DM Hypercholesterolaemia Cardioembolic (AF, valvular heart disease, atrial myxoma) Optic neuritis Post viral Demyelinating disease (multiple sclerosis) Infective (Syphilis, TB) Optic atrophy Post optic neuritis / retrobulbar neuritis Secondary to Glaucoma Ischaemia (Post CRAO, AION) Neurodegenerative disease (Friedriechs Ataxia, SCA) CRVO/BRVO: HPT DM Hypercholesterolaemia

Cherry red spot: Tay Sachs CRAO

Angioid streaks: Pagets, Pseudoxanthoma elasticum Acromegaly Sickle cell anaemia Hyperphosphataemia

Retinitis pigmentosa Lawrence-Moon-Biedl syndrome Refsums Friedriechs ataxia Abetalipoproteinemia

280

COMMONLY ASKED QUESTIONS - OPHTHALMOLOGY 1. What are the eye manifestations associated with DM? a. Retinopathy: background retinopathy, preproliferative and proliferative retinopathy b. Maculopathy c. Vitreous haemorrhage d. Cataract e. Rubeotic glaucoma f. Refractive error secondary to glycaemic related lens osmotic changes How will you manage this patient - DM with proliferative retinopathy? a. Optimize glycemic control b. Achieve target BP c. Optimize lipid control d. Reduce proteinuria nephropathy ACE inhibitors e. Patient education importance of compliance, s+s of hyper- or hypoglycaemia f. DM foot care g. Laser therapy for retinopathy What are the signs of Graves ophthalmopathy? a. Exophthalmos, proptosis b. Lid retraction, lid lag c. Chemosis, ophthalmoplegia What are the complications of Graves ophthalmopathy? a. Ophthalmoplegia with diplopia b. Exposure keratopathy c. Compressive optic neuropathy What are the complications of CRVO? 100 days glaucoma How to dfferentiate clinically among the following 3 conditions? i. Orbital apex syndrome ii. Cavernous sinus thrombosis iii. Tolosa Hunt Syndrome All the above 3 conditions presents with ophthalmoplegia, but a. Orbital apex syndrome has reduced visual acuity, usually unilateral. There is no orbital pain/chemosis in orbital apex syndrome. b. Cavernous sinus thrombosis can present with chemosis, eye pain, proptosis, 3,4,6 nerve palsy. V1 or V2 may be affected (facial numbness), usualiy spread to involve contralateral eye very fast c. In tolosa Hunt Syndrome/superior orbital fissure syndrome, pain is prominent

2.

3.

4.

5.

6.

284

QUIZ - OPHTHALMOLOGY Describe the abnormalities seen. Systematically run through your mind how you will approach the patient. Rehearse how you will present your findings, diagnosis and differential diagnoses. Answers will be in the following pages.

Figure: 10.1

Figure: 10.2

Figure: 10.3

Figure: 10.4

Figure: 10.5

Figure: 10.6

285

Figure 10.21, 10.22

Describe the abnormalities seen Dot blot and flame shaped haemorrhages, hard exudates at the macula, cotton wool spots New vessels elsewhere at inferonasal vessel

Diagnosis Proliferative Diabetic Retinopathy (PDR) + diabetic maculopathy

Commonly asked questions

10.23

Extensive circinate hard exudates at the macula Dot & blot haemorrhages

Non-proliferative Diabetic retinopathy with clinically significant macular oedema (CSME) PDR with diabetic maculopathy

10.24

Neovascularisation at disc (NVD), hard exudates at the macula, dot-blot hemorrhages Neovascularisation elsewhere (NVE) with preretinal haemorrhages

10.25

PDR

10.26

Neovascularisation elsewhere (NVE) with preretinal haemorrhages Fibrous membrane Photocoagulation burns

PDR

10.27, 10.28

Extensive fibrous membrane along the superior and inferior arcade Premacular haemorrhage and vitreous haemorrhage

Advanced diabetic eye disease with fibrous traction and vitreous haemorrhage

10.29

New vessels at disc (NVD) and elsewhere (NVE) with vitreous haemorrhage Hard exudates

PDR with vitreous haemorrhage

10.30

Recent photocoagulation burns (white) and scar (hyperpigmented) over superolateral quadrant

Diabetic retinopathy with laser scar

292

SECTION 11 RADIOLOGY
Case Studies in Diagnostic Imaging
Dr. Dennis Tan Gan Pin

INDEX OF CASES Spontaneous pneumothorax Alveolar pulmonary oedema Left lower lobe pneumonia Right upper lobe collapse Pulmonary tuberculosis Miliary tuberculosis Hiatus hernia Retrosternal goiter Ankylosing spondylitis Dissecting aortic aneurysm Pulmonary embolism Achalasia Liver cirrhosis with hemochromatosis and hepatocellular carcinoma Non Hodgkin's Lymphoma Medullary nephrocalcinosis Chronic calcifying pancreatitis Adrenal adenoma/incidentaloma Extra-adrenal pheochromocytoma/paraganglioma Thyroid ophthalmopathy Ectopic parathyroid adenoma Pheochromcytoma Septic emboli causing pulmonary infarcts Dural venous sinus thrombosis with sinusitis and mastoiditis Cerebral toxoplasmosis Osmotic myelinolysis 294 295 297 299 300 301 302 303 304 305 306 308 309 310 311 312 313 314 315 316 318 319 320 322 323

293

SECTION 12 APPENDICES

A. Common short cases in Asia vs UK B. Approach to common short cases C. Examples of presentations D. Common cases with lists of investigations E. Summary of signs to look for in various systems/stations F. Principles of management of common cases G. Neurologic localization H. Summary of investigations and management of common neurological disorders I. Summary of investigations for lower motor neuron disorders J. Samples of real PACES examination cases

325 326 329 334 337 339 341 342 343 344

324

Cardiovascular (CVS) cases: Approach to Young HPT This patient has young hypertension, examine him. a. Look for signs to suggest underlying cause/secondary HPT: Sallow (CRF), SLE facies Endocrine facies (thyrotoxic, Cushings, acromegaly) Radiofemoral delay (Coartatation of aorta), pulseless (Takayasus disease) Abd mass (adrenal gland tumor/pheochromocytoma),ballotable kidney (polycystic kidneys), renal bruit (renal artery stenosis) b. Look for signs to suggest any complications that have set in: systemic arterosclerosis, reduced pulse volume (peripheral vascular disease), carotid bruit, displaced apex, S4, LVF, stroke with facial asymmetry, hemiparesis, hypertensive retinopathy. This patient complained of frequent palpitation, examine her. Patient has atrial fibrillation (AF): a. Look for signs to suggest underlying cause: Thyrotoxicosis: exophthalmos, anxious, agitated face, goitre. Malar flush (mitral stenosis), submamilary valvutomy/median sternotomy scar for any valve replacement. b. Look for signs to suggest any complications that have set in: stroke with facial asymmetry, hemiparesis, bruises (overwarfarinization). c. Ask for history of HPT, IHD that may be associated with AF. Approach to Xanthelasma a. Elicit all the signs of hyperlipidaemia eg. tendon xanthoma over elbow, knee, archilles tendon. b. Ask for permission to inspect the buttock for any eruptive xanthoma, proceed to examine fundoscopy for any lipimia retinalis. c. Also look for any signs to suggest associated complications of hyperlipidaemia eg. CABG scar (IHD), hemiparesis (stroke) Approach to Angina a. Look for signs to suggest underlying cause: Obesity, xanthelasma, nicotine stained nail, CABG scar (IHD), unequal pulse, trophic changes over foot to suggest associated peripheral vascular disease, hemiparesis (stroke) Nervous system Approach to Young stroke Look for signs to suggest underlying cause: xanthelasma, corneal arcus, nicotine stained nail, vasculitic lesions, stigmata of infective endocarditis (splinter haemorrhage), HPT, IVDU mark, polycythaemia, carotid bruit, mitral flush (mitral stenosis), submamilary valvotomy/median sternotomy scar for any valve replacement, Dystrophia myotonica a. Comment on frontal balding, bilateral partial ptosis, wasting of temporalis and masseter muscles. b. Elicit myotonia by shaking patients hand, demonstrate percussion myotonia by tapping over patients brachioradialis using tendon hammer, tapping the tongue with spatula for any guitar sign. Examine cardiovascular system for any signs of congestive cardiac failure as well as any endocrinopathy (Thyrotoxicosis, diabetes). c. Examine eye for any cataract.

327