Sleeping a little too much?

One of the patients that I encounter this morning during the Psychiatric Liaison round. 41 year old gentleman was referred to the PSY team for methadone replacement therapy. He is an ex heroin addict presented with 2 days history of altered consciousness and excessive drowsiness. The wife claimed that he was unusually sleepy and tired over the few days prior to admission. There were no documented fever, seizures, limb weakness. Systemic reviews of the cardio, respi, genitourinary system were unremarkable. FBC was normal with total WCC of 6x10^9. Comment on the CECT findings and I will post up what was reported by the radiologist.

Causes of 3 figure ESR

I was taught by my prof that there are 5 common causes of a 3 figure ESR:

1) Multiple Myeloma

2) Polymyalgia Rheumatica/Temporal Arteritis

3) SLE

4) TB

5) Advance Malignancy

Though these are common causes, they are not definite or exhaustive. I have actually came across a lady with rhrumatoid arthritis having an ESR of 120mm/hr.

This gentleman presented with 1 year history of chronic back pain that worsened over the past 4 months. His condition deteriorated 2 weeks prior to admission and he was unable to ambulate independently without the aid of crutches due to the pain. Multiple X-rays were taken and showed

His ESR was 114mm/hr. What's the diagnosis?

Rash?

8 year old boy presented with arthralgia, abdominal pain, maculopapular rashes and renal impairment.

Myelomeningocele

亲爱的宝贝，再撑一下

Acromegaly

Courtesy of Dr Fadzli, Endocrine MO

1)Spend a few seconds in general inspection

2)Start off by examining the patient's hand, you notice that he has spade-like, sweaty hand, the skin is thickened and doughy.

3)Check for carpal tunnel syndrome(Phalen and Tinel Test)

4)Look at the face-check for prognathism(causing malocclusion of jaw), prominent supra-orbital ridges, wide inter-dental spaces and macroglossia

5)Offer to look for skin tag(molluscum fibrosum) at axilla

6)Look at lower limbs for pitting edema to suggest cardiac failure, look for evidences to suggest osteoarthritis of the knee, thicken heel pad

9)Check for proximal myopathy by asking patient to squat down

10)Assess the visual field to look for bitemporal hemianopia(acromegaly tends to be due to macroadenoma)

After eliciting all the positive signs, suggest to examiners you would like to complete your physical examination by

1)Check the blood pressure which is an indicator for active disease process

2)Check urine for glycosuria

3)Check fundus for DM/HPT changes

4)Examine the cardiovascular system for heart failure, neck for goitre and abdomen for hepatosplenomegaly

Questions

1)How do you confirm the diagnosis?

2)What are the modalities of treatment available?

3)How do you monitor treatment response?

4)Any endocrine syndrome which is associated with acromegaly?

Liver Atlas and Casebook

Was browsing through the book collection in the HDOK library and came across this book titled “Liver Atlas and Casebook” edited by our very Malaysian Director General of health, Dr Ismail Merican himself. I highly recommend this book for students like me out there as it highlights important concepts pertaining to the diagnosis and management of common diseases that affect one of the largest organs in our human body- the liver. On the other hand, this book compiles a number of complex cases, which were managed by the highly specialised team in our very own hepato-biliary excellence centre- Selayang hospital. Overall rating of 8/10 with high resolution pictures of specimens for an in depth understanding of the pathology of most liver diseases. Some of the important facts that I’ve gathered after finishing ¾ of the book.

• The text book triphasic CT characterisation of HCC

Arterial enhancement as HCC derives its blood supply from the hepatic arterial circulation

Complete venous washout

• HCC usually causes thrombosis of the portal vein and its branches. Jaundice is not a common presenting feature of HCC.
• Diagnosis of HCC rarely depends on liver biopsy due to potential tumour dissemination that may convert a resectable lesion into a non resectable disease.
• Among the common presentations of HCC is abdominal pain/discomfort usually felt as a dull sensation, awareness of abdominal mass/constitutional symptoms of appetite and weight loss. Jaundice and ascites develop in later stages of the disease, when present contraindicates surgery.
• Serum AFP may be normal in up to a third of patients with HCC
• Text book CT characterisation of FNH(Focal Nodular Hyperplasia)

Hyperdense vascular enhancement with central hypodensity (stellate scar)

• FNH usually does not require intervention unless patient is symptomatic/ uncertain and suspicious for malignancy
• The most common benign liver lesion-hepatic haemangioma that is usually picked up incidentally.
• Leptospirosis is caused by “Leptospira Icterohaemorrhagiae”. Rats are common source of human infection. It can also infect cattle shoes and swine. Incubation period takes about 10 days (average)
• Adolf Weil was the first person to document this disease and thus severe form of leptospirosis is also called Weil Syndrome.
• Jaundice and haemorrhagic manifestation are not uncommon, hence the name “Icterohaemorrhagiae”
• The leptospires, directly/through immune mechanism damage blood vessels, cause centrilobular necrosis of the liver, renal tubular dysfunction by causing interstitial nephritis and acute tubular necrosis. Diagnosis is based on serology with 1:800 being diagnostic.
• Liver abscess usually shows up as a hypoechoic area with some debris within it. ( On ultrasonography)
• K.Pneumonia has emerged as one of the most common pathogen responsible for liver absvess
• Metastatic infections are commonly seen in patients with K.Pneumoniae liver abscess. They are

Enopthalmitis

Septic Pulmonary embolism

Pulmonary abscesses

Cerebral abscesses

Purulent meningitis

Otitis media

Osteomyelitis

Prostate abscess

Psoas muscle abscess

• In a patient with abscesses in multiple sites, K.Pneumonia infection should always be considered as a possible cause
• Polycystic disease of the liver is a benign condition which usually presents as an incidental finding or abdominal discomfort/pain/mass
• Occasionally an infected cyst would present with pain and fever
• In a patient with abscesses in multiple sites, K.Pneumonia infection should always be considered as a possible cause
• Polycystic disease of the liver is a benign condition which usually presents as an incidental finding or abdominal discomfort/pain/mass
• Occasionally an infected cyst would present with pain and fever