long case pcm

7/29/2019 Long Case PCM

1/10

Long case PCM/Med

Lim Xin Jie

1. lecturers who took u-prof philip poi,prof dharmendra,prof cheah-external paed

2. specialty-PCM/Med

3. chief complaint-right big toe swelling-1st presentation(10 years ago)

4. brief history -during the 10 years, multiple joint involve as well.but everytime 1 joint...ass stiff

and affect function..ambulating wheel chair after 3 attack..last attack 2 years ago,right knee pain

ass swelling and fever..background history of HPT.

5. PE finding-cushing facies + u all noe,deformity finger(boutonnier),fix left ankle joint.

6. diagnosis-gouty arthritis,uncontrol HPT,steroid coz cushing n mayb metabolic

7. questions asked by lecturer-what investigation u want to do?he want ESR and CRP and uric

acid...

-is it uric acid normal meant no gout?no

-whic joint aspiration u want to take?mid size joint

-what u see in aspiration?monosodium urate crystal, negative birefringent..

-how u like to manage? NSAIDS-indomethacin

-S/E NSAIDS?UGIB,gastritis,...

-others TX-allopurinol..when u wan to start?after d acute attack?why??i answer will aggravated d

acute state..then prof philip said nwm..is HIGH5

-others Mx-rehydration,diet and control HPT..-what do u think about the Med Compliance...

-how u assess d compliance med of this patient?

there are still questions will b asking during history and PE...n i m sharing patient with perak

students...

about a week ago Report

Salahuddin Abd Jaafar1. lecturers who took u: Prof Khoo Ee Ming (PCM), Prof Adeeba Kamaruzzaman (Medicine), Dr

Zygmunt (External, dia senyap sepanjang masa)

2. specialty: Medicine and PCM

3. chief complaint: come for exam. currently under follow up for:

endometrial Ca (post-TAHBSO)
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2/10

asthma

deep vein thrombosis

obesity and Diabetes Mellitus (ini main problem dia)

4. brief history

suhaili, 35, malay, ladya) asthma, since childhood, well controlled, currently on bicotide and ventolin

b) dvt, currently on warfarin 8mg OD, INR:2-3, well controlled

c) endoM Ca, done TAHBSO, 15 round of chemo, and brachytherapy. currently well, no sign of

mets/recurrence

d) Diabetes: currently on metformin 850mg, diamicron 1 tablet OD, insulatard 10U before bed. last

follow up HBA1c is 12.1. Poorly control. claim take medication and controll diet. however do not

exercise.

5. PE finding (positive finding only)

random blood sugar: 13.1mmol/l

obese: BMI 37.37

left leg swelling with varicose vein

6. diagnosis

uncontrolled DM with obesity. and currently on medication for DVT

7. questions asked by lecturer

during PE: demonstrate how u confirm swelling, what is the causes of unilateral leg swelling, when

patient started to develop diabetic neuropathy as this patient only diasnosed DM incidentally for 3

years, what can be the causes of the swelling in this patient (lymphoedema???)

back in room: what is the current status of her DVT, what is the patient current concern(uncontrolled DM), if HBA1c is 11.1 what does it means, what other investigation would you do for

this patient, in UFEME if protein 1+ what does it means, (contamination??UTI??), how to rule out

this, other investigation, give all other investigation and managament for DM in this patient. (ting

tong... times up). that's all i managed to get asked.


1. lecturers who took u-prof nik sherina(pcm),prof CLL(dia diam je),external examiner(dia ni diam

je n siap tido)

2. specialty-pcm/med

3. chief complaint-exam(no active complaint)
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3/10

4. brief history-69/M/M--dm, hpt more than 15yrs, gout, IHD 6yrs

5. PE finding-all normal, except loss of vibration(lecturer ask to demonstrate how to check

peripheral neuropathy, how ti palpate cardioM, cannot feel, even on left lat position, so had to

percusss)

6. diagnosis-dm, hpt,

7. questions asked by lecturer - DM HPT Cx, causes of blackout (patient claimed had MVA d2

blackout), interpret pt result, other Ix beside blood, how to calculate ot creat from age, side effect of

drug-statin-myositis, y sodium low in this pt(not sure which drug cause it), what advice you wanna

give the pt regarding the disease-control etc, advice on how to make pt compliance to meds.

about a week ago

Raymond Kok

same patient as Salahuddin Abd Jaafar

1. lecturers: Prof Khoo Ee Ming (PCM), Prof Adeeba Kamaruzzaman (Medicine), Dr Zygmunt

(initially silent)

2. specialty: Medicine and PCM

3. chief complaint: no active complains. came in for exam.

under follow up at RUKA and O&G for:

endometrial Ca (post-TAHBSO)

asthma

deep vein thrombosis

obesity and Diabetes Mellitus

4. brief history

suhaili, 35, malay, lady

a) asthma, since childhood, well controlled, currently on bicotide and ventolin

b) dvt, currently on warfarin 8mg OD, INR:2-3, well controlled. had 3 episodes

c) endoM Ca, done TAHBSO, 15 round of chemo, and brachytherapy. currently well, no sign of

mets/recurrence

d) Diabetes: currently on metformin 850mg, diamicron 1 tablet OD, insulatard 10U before bed.

5. PE finding

left leg swelling with varicose vein
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4/10

20cm Pfannenstiel scar post TAHBSO

6. diagnosis

uncontrolled DM with obesity. and currently on medication for DVT

7. questions asked by lecturerduring PE: please examine her lower limbs.

demonstrate how u confirm swelling (measure circumference of calf), what is the causes of

unilateral leg swelling, what can be the causes of the swelling in this patient (uterine ca mets

compressing on lympahtic drainage of left lower limb)

back in room: how would you manage this patient knowing that she has the above problems (INR

monitoring, Diabtetic control and complication detection), what blood Ix would you do for her? if

HBA1c is 11.1 what does it mean and what should you do?

if protein 1+ what does it means does it mean she has diabetic nephropathy? what are the other

causes? what sort of diet regime do you know of? her current BMI is 37.7, what should be the

ideal? (18-22.9 for asians)

that's still a long way to go for her and they laughed among themselves

good luck ppl..


SOh RezaProf Sajar (sangat baik dan supportive), Prof Mary Ann (dok senyum sampai abis exam) and Prof

Lucy Lum

Primary Care Medicine

Chief complaint

Currently, came for exam purposed, but presented 15 years ago with chief complaint of seizures for

one day duration

Brief history

44 years old Malay gentleman

He was apparently well until 15 years ago, when he first develop seizureswhile sleeping (around

3-4am in the morning)

- Upper limb held in flexion postion

- Drooling of saliva

- Bitting of toungue

- Uprooling of eye ball
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5/10

- Last for 5-10minutes

- Noticed by his wife

- Nothing much done by the wife as she was panicking

Post ictal he developshort term memory loss(canot remember the date,time,whether hes working

or not)

- lasted for one hour- associated with dizziness

For the first time, did not seek medical attention as he taught it was normal.

Then 3-4months later, develop second episode which was similar the first one but still did not seek

for medical treatment

Only for the third time he seek for medical attention as it was advice by his uncle

So within one week, went to Hospital Tampin and was refer to PPUM for further investigations

In PPUM, he was arranged for EEG was told the result was positive and was started on tegtigrol

for 3months and withdraw because of side effect (rashes)

Then medication was change to phenytoin until now

Since 1997 up to now, his condition was improving (frequency of attack 1-2 times/ year) compared

to previous one (3-4 times per year) and less bleeding of tongue bitting

For complianceAttend regular follow up (6 monthly), compliance to his medication, never miss

medication

- Last attack 6 months ago

- Last follow up last 2 weeks, also noted BP high (140/90)

Social history - Not affecting his jobs or daily activity as it usually occur during sleep

- Chronic smoker for 20 years

- No history admission because of seizure

Sytemic reviewNo low, no loa, no fever, no chronic cough, no contact with tb, no hemoptysis

- No symptoms of hypoglycemia before attack

- No early morning headache, no nausea, no vomiting, no blurring of vision- No chest pain, no sob

- No olugouria, nocturia, urinary symptoms, no altered in bowel habit

- No calf pain during walking, intermittent claudication

- No history of MI/TIA/Stroke before

PE findings

O/ealert, conscious, responsive

- no pedal oedema

Vital sign

BP140/100

PR80bpm NV RR No SC

RR20breaths/min

T - febrile

CNS

Tonenormal

Power -5/5

ReflexIntact


6/10

SensationIntact

PlantarDowngoing

CVS

Unable to locate the apex beat (huhuhuhu)

S1,S2 heard, no murmur

LungHyperinflated with loss of cardiac dullness and liver dullness

Vesicular BS, equal air entry, no crepts or rhonchi

Urine Dipstick

Protenuria +1

Diagnosis

Epilepsy with hypertension

Questions asked

1. PEComment on peripheral xmNo pallor, no jaundice, no cyanosis, hydration status fair

- Elicit the upper limb reflexes (biceps)

- Demonstrate how you check for apex beat as I said I was unable to locate it

- Why do you think apex is not palpable in this patientBcos im shivering (they all laugh..huhuhu)

, wut else?

- Thick chest wall

- Hyperinflated lung (after prompt by examiner as she ask

the relation between smoking and lung

- Demonstate hyperinflated lung

- Show me the normal site for apex beat (pointing at 5th left

ICS)make sure show the midclavicular line and count the

intercostals space from 2nd- Did you check for the fundusIm sorry I didnt have much time to do that but I would like to

complete my

examination by checking fundus for hypertensive retinopathy, sign of papillodema

2. In the room

a. What do you think the patient hasEpilepsy

b. Why, give your reasonrepeated episode history of seizures

c. How do you think hes condition nowwell controlled and getting better with treatment as

frequency reduces (1-2times year) compared to previous one and currently tongue bitting less

bleeding

d. Is there any specific causing the seizuresfrom the history, I could not find any specific reason

for the seizures to occur as he had symptoms of low/loa, no fever, no cough, no contact with tb, no

hemoptysis, no family history of epilepsy/brain pathology, and only occur when he was sleeping

e. Let say the patient present to you for the first time, what are the things u should consider

Considering the age of patient & late onset of seizures, few differential diagnosis that I should

consider

i. Intracranial pathology such SOLbrain tumor


7/10

ii. InfectionsMeningitis, encephalitis, TB abscess

iii. Metablic disturbancesHypo/Hypernatremia, Hypocalcemia, Hypogylcemia

iv. AVM

f. For the metabolic cause, which one the most important cause of seizuresHypoglycemia (fair

enuf)

g. Let say the patient had brain pathology, how usually they presentEarly morning headache,nausea, vomiting, sign of papillodema

h. If u suspect the patient hat tumor in the brain, what investigations u wanna orderCT scan of

brain to look for the lesion/mass, location, the size, shape, infiltration to surrounding structure,

midline shift, inverventricular extension

i. Now the EEG show patient had epilepsy, what is your further management? List problem that

patient had now

i. Epilepsy well controlled

ii. High BP

j. For the epilepsyput patient on regular follow up, make sure he is compliance to medication, and

never miss medication

k. How to access pt compliance to medication other than asking him(lost for a while), what are

expect to see in blood?

oh the level of drug within the blood system..huuhuhu

l. How do you advice patient for his epilepsy? What is the absolute contraindication for the sports

the he can not do?

Avoid driving the car (if possible ask the wife to drive the car), certain jobs (lorry, bus driver, use

the heavy machine like the construction site should be avoided), for activity (no cycling, swimming,

suddenly terkeluar football (zzzzz,then examiner ask why?hahahahh)

m. What about the high BP

Lifestyle modificationsmoking cessation, regular exercise, reduce weight

Suddenly KRINGGGGGGGGGGGG!!!!!!GOSH!!!!Tak sempat abiskan..huhuhuuh

P/S: Hopefully we all can pass..The examiner is very nice and try to help to so that we can

pass..Gudluck everyone=)

last Monday Report

Ka Kiat Chin

1. lecturers

prof Sajar (PCM), prof Lucy (Paeds), prof Mary (external)
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8/10

2. PCM

3. Chief complaint

came for exam

4. History

44/m/gentleman, dx with epilepsy for 14 years. no previous admission in ppum, follow in ruka. last

attack on oct 2010 due to stop taking drug for a week. GTC during sleeping, on phenytoin no

complications. no other medical illness. still driving

5. PE

no finding. asked to show the signs of focal lesion (increased ICP) : papiloedema, unequal pupils,

visual field (HH and bitemporal hemianopia), diplopia (LR6).

Phenytoin SE: signs of anaemia, gum hypertrophy.

bp 140/100

6. diagnosis - epilepsy

7. questions:

wat psychological illness associated with chronic disease?

investigations when patient follow up in clinic

long term management?

advice to family members when seizures happen?

advice on smoking? (prof lucy)

driving issues?

will u diagnose him hpt on single reading?last Tuesday Report

Ngui Ling Xiu

1. lecturers who took u: prof nik sherina, prof philip, prof (i guess fr surgery dept coz always saw

him walking around surgery dept, indian guy, thin tall, curly hair, middle age, dunno who)

2. specialty: PCM

3. chief complaint: recruited for exam by mohazmi

4. brief history: uncontrolled DM, HPT, hyperlipidaemia, BPH. Polio at age of 5, complication
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9/10

OKU, present all then summarize, they are quite patient i think.

5. PE finding: Bedside examination of UL inspection, right side, wasting of thenar muscle, foream

muscle wasting, median nerve affected, examine ulnar and radial normal. Then examine UL motor,

patient compensated the elbow extension by shoulder pushing forward. Then lower limb inspection,

wasting of left lower limb, objective measuring the circumference, then check the vibration ( profphilip ask how to check if patient REALLY feel the vibration??? coz u touch the pt oso noe, but he

said i m not saying that the patient will tell lies, later ans will be comparing with chest, the ques

sounds interesting but answer he want weird). Fundoscopy silver wiring, pt eyes dilated to pupil

size 9mm. Others bedside examination i do urine examination all they did not ask.

6. diagnosis: explain about the findings, poliomyelitis, ant horn cell then lower motor neuron


Ask about investigation.... reason

Then ask about some issues like lisinopril caution b4 giving, renal artery stenosis, rule out u/s, renal

bruits. Management if patient still uncontrolled DM, how to start insulin, prebed, dosage. Pt with

family hx of colorectal ca, pt came what will you tell him, later prof ask how to screen him easily,

fecal occult blood. The side effect of the drugs, metformin, gliclazide, lisinopril. Last ques if pt

cannot tolerate lisinopril, present with cough, what will you do, change ACE to ARB, then prof

philip ask what is ARB??? suddenly thought block, then all of them hinting, the surgery prof who

was silent for whole day suddenly so excited n hinting also. Finally, bell rang and oh i remember,

angiotensin receptor blocker, haha... I heard prof sherina said to prof philip ya, we all experience

this too, haha. She was so kind;)Thanks GOD for giving me health, cooperative patient, and nice

examiners!

last Tuesday

Nor Haslinda Zainuddi

1. lecturers who took u : Prof Khoo (PCM), Prof Raman (paeds surg), Prof Mary? ( external ONG)

2. specialty: PCM

3. chief complaint:

- No c/o la, come for exam...huhu.. history of dm n hpt for 16 years and dyslipidaemia for 8 years.

4. brief history

- DM control not so good even compliance to medication. HPT reading is good. LDL and HDL not

in normal range. educated person( an addmath teacher) and very nice. diet not really control n
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10/10

exercise less. ho other DM cx like IHD or diabetic nephropathy. previous eye check up shows

peripheral hemorrange. dis pt got ED and on viagra.

5. PE finding

- All normal except presence of skin lesion in DM and I'm not sure about the skin lesion so better

know in and out bout DM k.

6. diagnosis

-DM n HPT with dyslipidaemia with no symptoms of hyperglycaemia.


-Diet for diabetic patient.

-How do u manage pt with HBA1c > 8?

-Target HBA1c for dis pt?

-Bedside: perform peripheral neuropathy examination and palpate pulses.

-Ix for dis pt

-side effect ARB and when u cannot use ARB?

on Thursday Report
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long case pcm

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