An old diabetic with swelling Rt. Thigh

History:

A 65 year old male, diabetic for 10 years and hypertensive for 15 years, taking sulfonylureas was admitted to the ER with a painful swelling right thigh for the last 3 days. He elaborated that he was trying to kick start his bike when he felt excruciating pain in the right thigh. He was unable to bear weight on that leg after that.

Examination:
On examination, he had a 5X5cm red swollen swelling invloving the anteromedial aspect of right thigh, located near the inguinal region. On palpation, it was hot, red, tender and no movements were possible at the hip joint due to pain.

He had no history of ischemic heart disease or a cerebrovascular accident. The fundi showed a normal fundus, with no sensory impairment in the hands and feet. His HbA1c was 7.2%. He had a history of nephrotic proteinuria, which responded to steroids. He was still on 30mg prednisolone.

Questions:

1. Give three differential diagnosis.


2. Name three first-line investigations.


3. Supposing the tender swelling as an abcess, name the likely organism and the empirical antibiotic.


4. Do the steroids need to be stopped to control the infection?

The CT scan showed a pus-filled area in the planes of adductor magnus muscle. The culture grew S. aureus.

The patient didnt respond to 5 days of ceftriaxone and amikacin, and was operated upon.

Obstructive Sleep Apnea

History:

55 year old, morbidly obese female presented with complaint of shortness of breath for last 2 years. This has increased in severity over the period of last 2 months, now restricting her to minimal activity. There is history of orthopnea and paroxysmal nocturnal dyspnea for the same period. Patient complains that she has not been able to sleep for many months, and it has become impossible for her to lie down flat.

On positive questioning, she further told that, there were apnoic spells during sleep, to start with. She used to snore a lot. Later she became unable to sleep at all. She used to remain drowsy all day long and could not do her routine household work.

She is post menopausal, and there is no history of menorrhagia. There is no history compatible to IHD. She is a non-smoker.

Examination:

Patient is little drowsy but in obvious distress with respiratory rate of more than 30. She is cyanosed (both central and peripheral), with hyperemic palms, and bounding pulse. Heart rate is 45/min, regular. No rise in JVP seen.

Cardiovascular system exam revealed marked bradycardia, loud P2, and probable murmur of Tricuspid Regurgitation.

Respiratory system exam was non-yielding as we were unable to pick up any finding because of thick chest wall.

Labs:

CBC showed microcytic hypochromic anemia.

Liver and Renal function tests were essentially normal.

ECG showed sinus bradycardia, while normal voltages.

ABGs showed a non-compensated type 2 respiratory failure.

QUESTIONS AT WARD ROUND:

1. What are the clinical criteria for Obstructive Sleep Apnea?
2. Can you name five different diseases which may lead to OSA? What could be the predisposing factor in this patient?
3. Why this patient is not having polycythemia?
4. What is the medical management for OSA?
5. What is the difference between CPAP and BiPAP? which one is preferred here?
6. What are the indications for Home Oxygen Therapy? How should we institute it?
7. Name five common complications of OSA?
8. What surgical procedure, if done early, will be most useful in preventing complications?

Pyrexia of Unknown Origion

A middle aged female presented with history of low to moderate severity fever of non-specific character for last 2 months. It is not associated with any sweating, anorexia, weight loss.

There is no systemic complaint.

Physical Examination revealed nothing remarkable except metallic heart sound at mitral area.

Past Medical History:

1. Had Rheumatic fever in late eighties.
2. Developed severe Mitral Valve Disease in early 2000.
3. Had Mitral valve replaced with a prosthetic metallic valve in year 2003.

Current medications:

1.Warfarin, and keeping her INR around 3.0, except that her last reading was around 6 and she had to hold her medicine for a couple of days.

2.Off and on use of digoxin.

3. ACE inhibitor

4. Aspirin

LABs:

1. CBC was normal, with 60% neutrophils

2. ESR came out 60 and it crept up on successive readings.

3. LFTs were normal

4. RFTs deranged, initial creatinine of 3.5 and a GFR of 19ml/min. (her RFTs one month back were absolutely normal), but over the period of one week it improved to 40ml/min.

5. Urine complete showed proteins 2+ and marked hematuria. Spot urinary Na was 35mmole.

6. ECG was normal

7. She was PanCultured and they all came out normal. (she took some quinolone for UTI few days back)

6. Her Serum C3 levels were normal.

9. Her Transthoracic echo revealed mild paravalvular regurge at mitral valve, but TOE confirmed absence of any vegetation.

An ID consultant reviewed her, and it was decided to treat her on the lines of enteric fever. She initially showed some response and was discharged therefore. We also gave her antimalarial cover on discharge. But she developed high grade fever and was readmitted few days later.

Plan: now we have planned to panculture her again, get her CT abdomen and pelvis. Her autoimmune profile is awaited. And we are thinking to get her bone marrow biopsy for Culture and Sensitivity. Any suggestions are welcomed.

WARD ROUND QUESTIONS:

1. What is PUO?
2. What are the common differential diagnosis?
3. How to plan for laboratory investigations?
4. What is empirical therapy, and what to treat in such case?
5. What is the plan of action if initial labs turn out nothing?

Parkinsonism

Clinical Scenario

• Disorientation for last 4 months
• Inability/decreased urge to move about

• Bed ridden
• Fixed posture
• Mask like face
• Generalized hypertonia, with equal resistance throughout the passive motion
• Positive Glebellar Tap
• ? palmomental reflex
• Eye movements could’nt be assessed as patient is not following command.

Past Medical History:

• Hypertensive: on some medication, could’nt be identified
• Ex-smoker
• Prior history of right sided CVA

Questions at WARD ROUND

• What are the essentials of diagnosis?
• What are the other variants? Name three sydromes categorized as Parkinson Plus
• What are the commonest side effects of Levodopa/Carbidopa?
• What medicine should be stopped in case, if patient develops symptoms of urinary retention.?
• What are the poor prognostic signs?
• Can it cause dementia? is it reversible?
• Name reversible causes of dementia

Fungal Meningitis

A young female patient, with a past history of Pulmonary Tuberculosis 7 years back, presents with


History:

1. Headache for 3 months
2. Diplopia for 1 month
3. Fever, low grade, no night sweats but history of weight loss and anorexia.

Clinical examination :

• Positive Kernig's sign
• Marked neck rigidity
• Depressed patient.
• Squint, lateral rectus palsy on right side.

CT scan revealed nothing remarkable, normal ventricles without any meningeal enhancement or Subarrachnoid Hemorrhage.

LP done which revealed 3+ yeast cells, which were later confirmed to be Cryptococcus.

Now she had received antifungal therapy, and also repeated Therapeutic LPs for raised intracranial pressure. We are planning for neurosurgical management (shunt placement) for relief of headache.



?What could have predisposed to all that?
















Patient has come out to be HIV +ve, which was later confirmed with ELISA. ART will be started soon.

Sudden Parapalegia

Patient is known diabetic and hypertensive. Had many complications before presentation, like repeated development of diabetic feet and multiple ray amputations for it , mild retinopathy and nephropathy, on insulin therapy for last one month.




Current Issue:
Developed sudden onset urinary retention and it was followed minutes after by rapid onset parapalegia. His power is 0/5 in both lower limbs, absent ankle but exaggerated knee reflexes. A sensory level to painful stimulus of T5. Plantars could not be assessed.


?What could be the diagnosis?














Currently we are thinking on the lines of Anterior Spinal Artery Syndrome, and his MRI spinal cord is awaited.

StartUp

This is really going to be a Start Up for a series of posts.
We are group of residents in Internal Medicine. We are working in MEDICAL UNIT IV, SERVICES HOSPITAL LAHORE, PAKISTAN.
Here, me and my colleagues will Post their experiences regarding their bed cases, daily ward rounds in internal medicine, daily discussions they have about their patients and journal articles they discuss. We hope it will help many physicians and PGs in internal medicine.