Clubbing

It's been some while since I last wrote. I have been busy with Neurology. Well, this patient is a 60 years old Malay man who was admitted to my ward with progressive L sided weakness over a week. He is non toxic looking and there is no stigmata of chronic liver disease. He has been a chronic smoker. To tell the truth, I was rather upset that 2 of my house officers could not come to a conclusion even after I mentioned the gross clubbing in this patient.

I hope medical students reading this will practice what has been learned in medical student years.

This is a clear cut case of Ca lung with metastasis to the brain.

What I would like to stress here is - Do not forget the causes of clubbing !

Respiratory :

Ca lung

Pulmonary fibrosis

Bronchiectasis

Chronic suppurative lung diseases

Cystic fibrosis

CVS :

Congenital cyanotic heart disease

Eisenmenger syndrome

Infective endocarditis

GI :

Chronic liver disease (Cirrhosis)

Inflammatory bowel disease

Thyrotoxicosis (pseudoclubbing - acropachy)

Plantar Response - Other than Babinski

Other than Babinski sign, what other signs do you know ?

In upper motor neuron lesion, the big toe will dorsiflex with the following :

Gordon reflex – On applying pressure to the muscle of the calf

Oppenheim sign – on applying heavy pressure with thumb and index finger to the shin, stroking downwords from below the knee down to the ankle

Bing reflex – when the dorsum of the toe is pricked with a pin

Schaefer reflex – pinching the Achilles tendon sufficiently to cause pain

Chadock reflex – on stroking the lateral side of the foot, beginning below the malleolus and extending anteriorly along the dorsum of the foot to the base of the big toe

Gonda reflex – grasping the small toes between the fingers, slowly and forcibly flexing the toe and then suddenly releasing the toe

I know an MRCP examiner who likes to ask this question. Try practicing it !  Physical examination is the most crucial step in Neurology.

Infectious Disease for MRCP Part 2a

39 years old 39 years old Malay Man presented with fever for 1 week associated with cough, yellowish sputum, pleuritic chest pain. No haemoptysis, loss of weight or night sweats. Chronic smoker. Also has diarrhoea for 1 week. 

Examination reveals clubbing, bibasal crepitations, hepatosplenomegaly. Multiple L/N enlargement.

Hb 10

WBC 4.1

Plt 43

Na 112 K3.2 U 3.8 Cr 69

 

pH 7.43 pCO2 2.4 pO2 9.8 HCO3 12 BE -10 SpO2 95%

What is your choice of treatment ?

A. IV Ceftazidime 2 g stat and 8H

B. IV (sulfamethoxazole and trimethoprim)Bactrim 3 ampules stat & qid

C. Isoniazid, Rifampicin, Ethambutol and Pyrazinamide

D. IV Acyclovir 500 mg stat and 8H

E. IV Amphotericin B 

MRCP PACES Course 2009

The time we feared most and the time we can't wait for it to be over. However, we choose to face it. PACES exam.....

We know that part of it is due to pure luck but if you are better prepared, the chances of passing is much higher.

Once again, Penang General Hospital, Seberang Jaya Hospital and Penang Medical College is planning for a MRCP PACES course the August 29 and 30. This is a soft launch for the course for those whom I am grateful for keeping up this blog. 

Thank you very much for the support. All entries are now closed. 

All the best !!

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Neurology Quiz

(Archieves of Neurology Vol 66 (No 4) Apr 2009

What is the diagnosis and what is the differentials for this ?

Tuberculous meningitis

A 45 year old man was admitted with a 3 day history of coma following 2 weeks of headache and fever. Examination revealed a GCS of 8/15, neck stiffness, and a complete R oculomotor nerve palsy. Examination of the CSF showed an opening pressure of 20 cmH2O, 800 leucocytes.mm3 (30% neutrophils, 70% lymphocytes), protein 180 mg/dl, CSF/ blood glucose 0.18. Gram and Ziehl-Neelsen stains of the CSF were negative. Culture of the CSF on Lowenstein Jensen media grew Mycobacterium tuberculosis.

(Adapted from Practical Neurology 2002)

This type of scenario can come out in the Part 1 or 2a MRCP and medical student exams. Not possible for PACES.

Name 3 complications of TB meningitis that may need neurosurgical intervention.

Meningitis

Photo taken form www.thereddragonhood.com/ images/rabbit.jpg

Text adapted from Archieves of Neurology (April 2009)

A 21 years old previously healthy man presented with 7 days cough with black and yellowish sputum, fever, chills, myalgia and pleuritic chest pain. 3 days before admission, had progressive worsening headache with neck stiffness and 8 episodes of watery diarrhoea

He had taken amoxycillin for 1 day

He had recently changed job, working as a professional landscaper 7 days before onset of symptoms

He had performed lawn mowing and leaf blowing services and noted he had dead rabbits in the areas he worked

T - 39.6 C, Alert, orientated to time, place, person

Stiff neck, no weakness or numbness

Lungs - bibasal crepts with exp ronchi

No lymphadenopathy,  skin lesions, ulcerations

CT brain - Normal

WBC - 10.4 (78% N) ESR - 40 mm/h

CSF - Cell count 1416/mm3, 19% N 73% L RBC 23, glu 41 mg/dl(glu 123 mg/dl), pro 2660 g/dl

Gm stain CSF -ve

CXR - N

MRI - cerebellar tonsillar herniation consistent with Chiary Type 1 malformation without evidence of brainstem syrinx

Treated with IV Ceftrixone and IV Vancomycin

Day 4 , headache worse and developed diplopia and nausea

Repeated LP -Opening pressure - 49 cmH2O, total nucleated cell count 2590/mm3 32% N 43%L 25% M, glu 28 mg/dL, pro 2950 g/dL (RBS - 128 mg/dL) 

Gram stain negative

What is the diagnosis ?