8

SECTION 2 LOOK AND PROCEED: SPOT DIAGNOSIS

A. Face

Systematically run through your mind if the patient has one of the following facies:

a. Abnormal habitus: Marfan’s, Gigantism, Turner’s syndrome, Osteogenesis imperfecta. b. Endocrine facies: Acromegaly, Cushingoid, Hypothyroidism, Hyperthyroidism c. Syndromic facies: Down syndrome, Turner’s syndrome. d. Neurocutaneous syndrome: NF-1, Sturge Weber syndrome, Tuberous sclerosis. e. 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, Wegener’s 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, Mee’s line

(arsenic poisoning). c. Rheumatological causes with Bony deformities/skin changes: RA, OA, gout, sclerodactyly,

Raynaud’s phenomenon, Gottron’s 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)

Skin lesions 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)

Cellulitis ± DVT DVT (Homan’s sign positive)

Venous ulcers ± Varicose veins

Swelling (pitting & non Pitting)

Pitting oedema (CCF, chronic liver disease, nephrotic syndrome) Non pitting oedema (elephantiasis/filariasis)

Wasting ± Foot drop, pes cavus, clawing of toes inverted champagne bottle (CMT)

9

Nose a. Saddle nose secondary to

- syphilis - Wegener’s granulomatosis, - yaws - recurrent perichondritis

b. Lupus pernio

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

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

Eye a. Pterygium b. Kaysier

Fleischer ring c. Iris nodule

Brushfield d. Spot in Down’s

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 Stevens- Johnson syndrome

f. Tonsillitis g. Peritonsillar abscess

(quincy)

Upper limb a.Shoulder

subluxation b. Ruptured bicep

tendon

Trunk a. Tattoo b. Photosensitivity

mark c. Spider naevi d. Gynaecomastia

Abdomen a. Renal Transplant

scar b. Sister Joseph’s

nodule c. Ascites d. Gray Turner’s

sign (due to retroperitoneal haemorrhage)

Hand a. Rheumatological causes with

Bony deformities/skin changes: RA, OA, gout, sclerodactyly, Raynaud’s phenomenon, Gottron’s papule

b. Abnormal finger length: arachnodactyly, pseudohypoparathyroidism (short fourth metacarpal)

c. Nail changes: clubbing, leukonychia, splinter haemorrhages, yellow nail syndrome, Mee’s line (arsenic poisoning)

d. Neurological causes of wasting: claw hand (unilateral, bilateral)

Buttock a. Tuberoeruptive

xanthoma b. Cutanous larva

migrans

Elbow a. Cubitus valgus b. cubitus varus c. IVDU

venepuncture marks

d. Patergy sign (Behcet’s)

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

10

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).

Cushingoid, pallor, Rheumatoid nodule ± Knee joint replacement scar.

Scars on the hand: dorsum (tendon repair); palmar wrist (carpal tunnel release)

Psoriatic arthritis Nail pitting, onycholysis, DIP swelling and tenderness.

Psoriatic plaque over scalp, retroaural region, extensor surface, trunk (periumbilical), buttock, Koebner’s phenomenon.

Osteoarthritis Heberden’s node (DIP), Bouchard nodes (PIP).

OA of knee, knee varus deformities.

Scleroderma Sclerodactyly, CREST syndrome (Calcinosis, Raynaud’s phenomenon, Telangiectasia).

Bird-like facies (pinced nose, microstomia) pulmonary fibrosis, oesophageal dysmotility.

Dermatomyositis Gottron’s papule. Heliotrope rash over face.

Neurological conditions: Unilateral hand wasting:

a. Brachial plexopathy

secondary to Pancoast’s syndrome

b. Cervical rib

c. Post traumatic brachial plexopathy

Clubbing, wasting of intrinsic muscles, ± nicotine stain.

Reduced sensation/ paresthesia over C8/T1.

Horner’s syndrome, ± trachea deviation, rib tenderness. Rib tenderness.

± Scar over neck.

11

Diagnosis Hand Findings Other Associated Clinical Features

Median or ulnar neuropathy (post traumatic, Hansen’s)

Bilateral hand wasting: I) Motor neuron disease

II) Syringomyelia

III) Peripheral neuropathy (eg. Charcot Marie Tooth)

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

Intact sensory with wasting of intrinsic muscles of hand (ape’s hand).

Dissociated sensory loss ± scars.

Hansen’s disease –thickened nerve, hypopigmented macule with hypoesthesia Post traumatic/plating scar over forearm.

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

Pes cavus, clawing of toes.

17

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 Chrohn’s disease on long term steroid complicated by upper gastrointestinal bleeding.

48

Respiratory system

A - Inspection B - Palpation C - Percussion D - Auscultation

Look for signs of Respiratory Distress

Asthma COPD Bronchiectasis Fibrosis Pleural Bronchogenic Ca

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

Look for signs of superimposed pneumonia, lung CA

Underlying dextrocardia, situs inversus

Underlying cause e.g. RA, scleroderma, CTD

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

Horner’s 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: Management: Management: Management: Management: Management:

• Bronchodilat

or • ± Antibiotics • Asthma

Action Plan

• Broncho-

dilator • ± Antibiotics • β2 agonist

(MDI/Neb) • Steroid

Antibiotics drainage

• Corticosteroid • Immunosuppre

ssive agent (Azathioprine, cyclophospham ide, cyclosporine)

• Oxygen • Diuretics if cor

pulmonale • Lung transplant

Pleural aspiration Chest tube insertion Pleurodesis a. Chemical:

talc, Doxycycline

b. Surgical

NSCLC/SCLC

- Surgery

- Chemotherapy

- Radiotherapy

49

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

148

SECTION 7 HISTORY TAKING

Tips on history taking 149

Cardiovascular System (CVS) a. Chest Pain 153, 156 b. Breathlessness/shortness of breath 153, 161 c. Palpitation 165 d. Infective Endocarditis 153

Respiratory System a. Cough

154, 167

b. Hemoptysis 154, 170

Gastrointestinal (GIT) a. Jaundice

154, 173

b. Abdominal pain 176 c. Chronic diarrhoea 154, 180 d. Pedal oedema 184

Neurology a. Headache

188 b. Syncope 155, 194 c. Fits 155, 198 d. Young stroke 154 e. Weakess of hands or legs 204

Haematology a. Anaemia

208

b. Bleeding tendency 209

Infectious disease (ID) a. Pyrexia of unknown origin (PUO)

210

Rheumatology a. Joint pain

211

b. RA 212 c. SLE 213

Genitourinary system (GUS) a. Proteinuria (Nephrotic) 214 b. Haematuria 215 c. Acute renal failure 216 d. Chronic renal failure 217

149

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).

2. 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 you’ve 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.

3. 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

4. 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

5. 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

6. 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.

7. The underlying cause can be classified as below:

Aetiology Examples C - Congenital Congenital malformation, Arachnoid cyst T - Trauma Head injury with brachial plexus/ root avulsion I - Inflammatory Acute disseminated encephalomyelitis (ADEM) I - Infective HIV, syphilis, tuberculosis (TB), cryptococcal

V - Vasculitis SLE, Wegener’s granulomatosis M- Metabolic Alcohol, toxic encephalopathy/neuropathy eg lead encephalopathy

and neuropathy N - Nutritional B12 deficiency N - Neoplastic Lymphoma, leukaemia, paraneoplastic syndrome D - Degenerative Cervical spondylosis, dementia I - Iatrogenic Drug induced Parkinsonism

P - Psychogenic Pseudoseizure

• Investigation:

160

Approach to Chest pain

Cardiovascular Respiratory Gastrointestinal Musculoskeletal

Ischaemic heart disease

(IHD) • Angina (stable/

unstable angina) • AMI (STEMI/

NSTEMI)

Dissecting Aortic Aneurysm

Pleuritic pain Pulmonary

embolism Reflux

oesophagitis

Costochondritis

Investigation: Investigation: Investigation: Investigation: Investigation: Investigation:

• ECG • Cardiac enzymes • Troponin Test

• Echo • CT angiogram

(CTA)

• ECG • CXR

• D-Dimer • Spiral CT thorax

OGDS ECG

Management: Management: Management: Management: Management: Management:

• STK (STEMI) • UH (STEMI) • SC Clexane (UA) • Risk factor

modifications

• Control

hypertension

• Surgery if involves proximal aorta

• Treat pneumonia • ±NSAIDS

• Streptokinase

(STK), rtPA • Thrombectomy • IV Heparin

Proton pump inhibitor (PPI)

NSAIDS

161

BREATHLESSNESS

1. Differential Diagnoses - CCF - COAD - Asthma - Recurrent Pulm. Embolism - Pleural Effusion - TB - Chronic Lung Disease: Bronchiectasis - Malignancy - Anxiety, Panic attacks - Anaemia

2. HOPC

- Signs & symptoms: S.O.B (onset, duration?)

3. 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

4. Aggravating factors

a. Exertion b. Food c. Smoke/dust d. Work

5. Relieving factors

a. Prop up b. Rest c. Medication: GTN, β-2 agonist inhalers.

6. Diagnosis of problem

- Any doctors treated you for similar complaints before? - Complication of problem & previous treatment? - Functional status now and comparison with before? - Progression

7. Medications

a. What has been prescribed? b. Any relief? c. Side effects of treatment. d. OCP. e. Precipitant of illness

- NSAIDS - worsening anaemia.

230

TIPS ON DEALING WITH UPSET PATIENT/RELATIVE

Stages and Objectives Examples 1 Introduce yourself • I am Dr Eow, the consultant in charge of the ward.

Explain role

2 Explore • Upset is usually due to the expectations not met or personal rules violated.

• If the patient’s 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.)

First try to understand why the patient is upset

3 Explain • (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.

Explain the current condition; what has been done

4 Express sympathy • 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.

5 Address concern • 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.

6 Reduce anger Apologise on behalf

• I am sorry. I apologised on behalf of my junior doctor. • I apologise on behalf of my team for whatever

shortcomings that had occured. 7 Remedial

action/corrective measure

• We promise we will do our best to avoid similar condition from occuring.

Find out what can be done/ improve the situation.

231

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 Examples 1 Introduction • Good morning Mr A, I’m 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?

2 Assess understanding

• Before I go on, may I ask what you have been told regarding your father’s condition?

3 Explain what has happened

• 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) • I’m sorry that you were not told regarding this.

Provide more information/

4 Give a warning shot • I’m afraid I’ve got some bad news to share with you……pause

5 Break bad news • During the scope, the scope accidentally torn the wall of your dad’s 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, I’m afraid your dad has passed away.

6 Express sympathy • I’m 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?

7 Dealing with anger • I’m 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.

248

SECTION 9 DERMATOLOGY

Common dermatology conditions 249 Blistering lesions 250 Psoriasis 253 Cutaneous malignancies 255 Cutaneous manifestations of systemic diseases 257 Cutaneous manifestations of systemic malignancies 259 Quiz - Dermatology 261 Quiz - Dermatology (More photos) 271

249

SECTION 9 DERMATOLOGY

No Dermatology Conditions Examples Commonly asked Question

1. Maculopapular rash - Drug reactions - Viral exanthem

What are the possible causes of maculopapular rash in this patient?

2. Vesicular/pustular skin lesions

- Chicken pox - HSV - Kaposi varicelliform - Pustular acne

Differential diagnoses Table to differentiate different lesions

3. Blistering lesions - Pemphigus - Pemphigoid - Dermatitis herpetiformis

Differential diagnosis Table to differentiate different lesions

4. Flexor surface: Atopic dermatitis

5. Papulosquamous disorders - Lichen planus - Psoriasis (Extensor surface)

6. Disorders of Pigmentation - Freckles - Chloasma

7. Cutaneous malignancies - Melanoma - Squamous cell Ca - Basal cell Ca

Melanoma-ABCD

8. Cutaneous manifestations of systemic malignancies

- Carcinoid syndrome - Dermatomyositis - Acanthosis nigricans - Icthyosis - Necrotic migratory erythema - Thrombophlebitis migrans

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

- SLE, discoid lupus - Scleroderma - Henoch Scholein Purpura

(HSP) - Sarcoidosis - DM dermopathy

10. Cutaneous infection - Staphylococcal scalded skin syndrome (SSS)

- Impetigo - Tinea - Lyme’s disease - Cutaneous TB - Cutaneous larva migrans

250

Blistering Lesions

Figure 9a: Pemphigus vulgaris

Figure 9c: Pemphigus vulgaris

Figure 9b: Pemphigus vulgaris

Figure 9d: Pemphigus folliaceus

251

Figure 9e: Bullous pemphigoid Figure 9f: Bullous pemphigoid

Figure 9g: Dermatitis herpetiformis Figure 9h: Dermatitis herpetiformis

280

Causes of common fundoscopic findings:

Papilloedema Optic neuritis Optic atrophy • Increased ICP (SOL, tumour,

abscess, Cryptococcal meningitis, TB meningitis, obstructive hydrocephalus

• Grade IV HPT retinopathy • Idiopathic intracranial HPT

(IIH, BIH, pseudotumour cerebri)

• Post viral • Demyelinating disease

(multiple sclerosis) • Infective (Syphilis, TB)

• Post optic neuritis / retrobulbar neuritis

• Secondary to Glaucoma • Ischaemia (Post

CRAO, AION) • Neurodegenerative

disease (Friedriech’s Ataxia, SCA)

CRAO/BRAO: Cherry red spot: CRVO/BRVO: • HPT • DM • Hypercholesterolaemia • Cardioembolic (AF, valvular

heart disease, atrial myxoma)

• Tay Sach’s • CRAO

• HPT • DM • Hypercholesterolaemia

Angioid streaks: Retinitis pigmentosa • Pagets, Pseudoxanthoma

elasticum • Acromegaly • Sickle cell anaemia • Hyperphosphataemia

• Lawrence-Moon-Biedl syndrome

• Refsum’s • Friedriech’s ataxia • Abetalipoproteinemia

284

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

2. 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

3. What are the signs of Graves ophthalmopathy?

a. Exophthalmos, proptosis b. Lid retraction, lid lag c. Chemosis, ophthalmoplegia

4. What are the complications of Graves ophthalmopathy?

a. Ophthalmoplegia with diplopia b. Exposure keratopathy c. Compressive optic neuropathy

5. What are the complications of CRVO?

100 days glaucoma

6. 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

285

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

292

Figure Describe the abnormalities seen

Diagnosis Commonly asked questions

10.21, 10.22

Dot –blot and flame shaped haemorrhages, hard exudates at the macula, cotton wool spots

New vessels elsewhere at inferonasal vessel

Proliferative Diabetic Retinopathy (PDR) + diabetic maculopathy

10.23 Extensive circinate hard exudates at the macula Dot & blot haemorrhages

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

10.24 Neovascularisation at disc (NVD), hard exudates at the macula, dot-blot hemorrhages

PDR with diabetic maculopathy

10.25 Neovascularisation elsewhere (NVE) with preretinal haemorrhages

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

293

SECTION 11 RADIOLOGY Case Studies in Diagnostic Imaging

Dr. Dennis Tan Gan Pin

INDEX OF CASES

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

324

SECTION 12 APPENDICES

A. Common short cases in Asia vs UK 325 B. Approach to common short cases 326 C. Examples of presentations 329 D. Common cases with lists of investigations 334 E. Summary of signs to look for in various systems/stations 337 F. Principles of management of common cases 339 G. Neurologic localization 341 H. Summary of investigations and management of common 342

neurological disorders I. Summary of investigations for lower motor neuron disorders 343 J. Samples of real PACES examination cases 344

327

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, Cushing’s, acromegaly) • Radiofemoral delay (Coartatation of aorta), pulseless (Takayasu’s 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 patient’s hand, demonstrate percussion myotonia by tapping over

patient’s 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.