FAKULTI PERUBATAN UNIVERSITI MALAYA JABATAN PERUBATAN. cpc. FASA filb, SES 2010t2012. Tarikh : 04 November 2011

Transcription

1 FAKULTI PERUBATAN UNIVERSITI MALAYA JABATAN PERUBATAN cpc FASA filb, SES 2010t2012 Tarikh : 04 November 2011 Masa : ptg Auditorium Klinikal

2 Questions 1. (a) Discuss your ditferentiat diagnosis based on the history and physical examination at presentation. (I2 marks) (b) What is your provisional diagnosis? (3 marks) 2. Interprethe following laboratory results, giving possiblexplanations; (a) Full blood count at the Emergency Unit. (b) Blood'biochemistry results atthe Emergency Unit. (c) The arterial blood gas analysis at the Emergenry Unit. (d) The arterial blood gas analysis in the medical ward. (3 marks) Comment on her chest radiograph (Figure 1) and radiograph of her hands and wrists (Figure 2). (10 marks) A Comment on the management during the first 6 hours of admission. (15 marks) s. (a) (b) (c) What was the diagnostic procedure? What was the abnormality shown in Figure 3? What was the diagnosis? (3 marks) (3 mark) 6. (a) State the finding on OGDS (Figure 4). (3 marks) (b) Name 2 possible aetiological factors for this finding in this patient. (2 marks) 7. (a) (b) Describe and interpret the ECG changes (Figure 5), List 4 risk factors in this patient which predisposed her to develop the problem in 7 (a). Describe the abnormal gross findings you would expect at autopsy. (12 marks) 9. Complete her death certificate attached. (10 marks)

3 Madam'Tan, a S8-year-old Chinese woman, presented to the Emergency Unit with a 3-day history of shoftiess of breath. She was diagnosed to have rheumatoid arthritis 3 years ago and was managed by her general practitioner. She was referred to the Rheumatology Clinic B months ago and was started on methotrexate 15 mg weekly and. prednisolone 5 mg daily. Her current medications were methotrexate 15 mg weekly, folate 5 mg weekly, prednisolone 2.5 mg daily and diclofenac slow-release formulation 75 mg twice a day. In addition, she had non-insulin dependent diabetes mellitus for l-0 years and was on glibenclamide 5 mg once a day. Her.blood sugar control had been satisfuctory. Five days prior to presentation, she developed fever and a productive coueh, The sputum was blood-stained on the day of presentation. Three days prior to presentation, she developed breathing difficulty which had become progressively worse. Madam Tan attained menopause 6 years ago and was on hormone replacement therapy until one year ago. She smoked 10 cigarettes a day for 25 years but she had stopped smoking 3 years ago. She had a strong family history of coronary artery disease. Her father died of myocardial infarction at the age of 56 years and her elder brother was diagnosed to have unstable angina at the age of 55 years. At the Emergency Unit On arrival at the Emergenry Unit, she'was in distress with a resplratory rate of 28 pei' minute and had a temperature of 38.9"C. Her pulse rate was 120 per minute and blood pressure was 110/70 mmhg. She had mild pallor but was not jaundiced. There was no peripheral or central ryanosis, She had multiple rheumatoideformities in both hands and wrists. Her apex beat was of normal character and was located in the 6h intercostal space 1 cm lateral to the mid-clavicular line. The first and second heaft sounds were normal and there was no gallop rhythm. Breath sounds were reduced and crepitations were heard over the right lower zone. Examination findings of the 'abdomen and central neruousvstem were unremarkable.

4 Results bf investigations performed'at the Emergenry Unit were as follows: Blood investigations Haemoglobin White blood cell Neutropitil Lymphocytes Basophil Platelet (g/l) (x1os/l) (o/o) (o/o) (o/o) (x1os/l) 110 2r Normal range ( ) (4,0-11.0) (40-7s) (20-4s) (0-1) (1s0-400) Sodium Chloride Potassium Urea Creatinine (pmol/l) I (136-14s) ( ) (3.6- s.2) (z.s- 6.4) (80-132) Glucose (mmoul) 10 (3.e- 6.1) Urinalysis Protein Sugar Ketone Red blood cell White blood cell (per high power field) (per high power field) -r +++ negative 1 8 (0-s) (0-10) Arterial blood gas analysis ph PaCO2 PaO2 Bicarbonate (kpa) (kpa) n n 19 (7.3s- 7.4s) ( ) ( ,0) (22-28) Radiographs of her chest (Figure 1), hands and wrists (Figure 2) were taken. In the medical ward She was admitted to the general medical ward and was given oxygen supplement and rehydrated with intravenous 5Vo dextrose/0.90/o saline sotution. After blood and sputum specimens were collected, she was started on an intravenous antibiotic. Methotrexate and prednisolone were withheld and intravenous hydrocortisone 50 mg daily was started, She was given subcutaneous insulin therapy consisting of 8 units of Humulin I three times a day and 8 units of Hirmulin L at night.

5 Six houfs after admissim, she became more breathless. The results of a repeatarterial blood gas lna[sis were as follorrys: ph PCO2 POz Bicarbonate kpa 7.8 kpa 16 mmoul She was electively intubated and mechanically ventilated A diagnostic procedure was performed. Microscopic examination of the specimen obtained confirmed the diagnosis (Figure 3). Antibiotic ilrerapy was changed accordingly. She improved 48 hours later and was extubated. Four days later, she was noted to be pale and tachypnoeic again. An oesophagogastroduodenoscopic (OGDS) examination was performed and the findings were as shown in Figure 4. A proton pump inhibitor was prescribed for her. At about 5.00 am the following day, she complained of vague chest discomfort and anelectrocardiogram (ECC) was done (Figure 5). One hour later, she stafted to sweat profusely and developed cardiorespiratory arrest. She died at 6.30 am and an autopsy was performed.

6 MG 502 No. Fihrasat: MEDICAL CERTIFICATE OF CAUSE OF DEATH CAUSE OF DEATH Approximate interval between onset and death I Disease or condition directly leading to death (a)...,.. due to (or a consequence of) Antecedent causes Morbid conditions, if any, Eiving rise to the above cause, stating the underlying condition last (b)... due to (or a consequence of) il Other signifi cant conditions contributing to the death, but not related to the disease or condition causing it

7 Figune '[ Figure 2

8 i 3*{ 6 t * t : Figure 3 Figure 4

9 Fig,r* 5 MEDI-TRACE. \ f