No kidney masses
Percussion = shifting dullness positive.
Auscultation = BS +ve, no renal bruit, no hepatic bruit or splenic rub.
I would like to finish my exam by examining DRE and genitalia.
What is your clinical diagnosis?
Pallor+ splenomegaly + Ascites
What is your DD?
CLD = PBC, hepatitis, AIH
Myeloproliferative neoplasms= CMl, PRV, Myelofibrosis , ET
Lymphoproliferative diseases.
Infections
Infiltrations
Chronic hemolytic anemia.
Investigation?
CBC, ESR, CRP
Viral serolgy
Uss abdomen, CT abdomen,
Autoimmune profile
PBF, BME, Jak2 mutations
Pararcentesis
This lady diagnosed as a case of portal vein thrombosis, how to manage?
Anticoagulants = LMWH, then oral Anticoagulants..
Communication question
She is lactating, would like to start warfarin or there is any other option ?
Unfortunately, there is not enough information about the safety of novel anti-coagulants to recommend them as first line treatment for breastfeeding mothers. At this point, warfarin ought to be the mainstay for oral anticoagulation therapy.
(CVS station)
A 70 year old lady, presnted with SOB+ palpation, 4 months back.
PlZ examine her CVS.
Old lady, mildly dyspnic in upright position,
No malar rash or peculiar features.
Hands= no clubbing, splinter hge, osler's nodules or janeway lesions
Pulse= irregular irregular, large volume collapsing.
No pallor or jaundice or cyanosis
Neck= jvp raised with mild hepatic Tenderness by hepatojugular reflux, arterial pulsations.
Legs= mild pedal edema
Precordium = no scars, deformity or visible pulsations.
Apex beat displaced
No heave or thrill
Auscultation = heart sounds irregular, PSM at apex radiated to axilla
Bases of lungs= few crackles.
No sacral edema
Your clinical diagnosis?
PSM, AF, decompensated HF
Your DD?
MR , AF , HF
How to investigate?
CXR, ECG, holter monitor, Echo, C.angio, CE, CBC, ESR, CRP, BNP, TFT .
What are the suspected findings in echo?
Valve lesions, Dilated ventricles with low EF, wall motion abnormalities
How to manage cardiogenic pulmonary edema?
O2, upright position, morphine, lasix, nitrates, NIV, IV, haemodialysis
What are options in long-term management?
AF= rate control, rhythm control, anticoagulants.
HF= diuretics, BB, ACEI, intresto, ivabradine, Devices, Transplantation.
MR= valve replacement.
Indications of surgery?
Symptoms of HF
Regurgitant fraction >50%, Regurgitant volume >50ml with LVEF 30_ 60%.
LVEF < 60%
LVESD > 50ml.
( Respiratory station )
An old man , presented with SOB.
Plz examine his respiratory system.
An old man, cachexic , comfortable in sitting position, not dyspnic.
Hands= no clubbing, no Tar staining, no palmar erythema, no fine or flapping tremor.
Eyes= pallor, no jaundice.
Mouth= no cyanosis.
Neck= no LAP or raised JVP.
Legs= no pedal edema.
Chest inspection = no scars, deformities or visible veins.
Palpation = decrease chest expansion mainly in the rt lower zone.
Percussion = dull percussion note at rt lower zone
Auscultation = absent air entry in the rt lower zone+ bronchial breathing at left upper zone .
What is your clinical diagnosis?
Dullness at rt lung base.
Bronchial breathing ( consolidation)
What is your DD?
Pleural effusion mostly secondary to malignancy.
Pleural thickening .
Collapse
Consolidation
Diaphragmatic paralysis
How to investigate?
CBC, Sputum analysis, ESR, CRP.
CXR, HRCT,PFT,
BAL, Bronchoscopy with biopsy, Video assisted open biopsy.
Pleurocentesis , pleural biopsy .
How to manage CA lung if there's mets to liver?
Chemotherpay, radiotherapy, palliative care
No role for surgery.
Communication question
المريض خائف من سحب السائل من الغشاء البلوري ، كيف تقنعه؟
عملية سحب السائل مهمة جدا في حالة حضرتك ، وذلك لأنه ستساعدنا في تأكيد التشخيص ومن غيرها قد لا نتمكن من الوصول للتشخيص، عملية السحب ستجرى تحت إشراف صورة التلفزيون وتؤخذ من منطقة آمنة وتحت إشراف أخصائي متمرس قد قام بها من قبل العديد من المرات ..
