International Mentor-ship Program Medicine TU.KSA

Dear Friends:
The department of Medicine College of Medicine Taif university is pleased to launch International mentor ship Program for medical fraternity 
You are welcome to interact with our faculty and seek guidance regarding clinical cases , research in the filed of medicine .
Hope all of you are enjoying our Blog which has now thousands of subscribers all over the Globe.Your suggestions to improve this service are most welcome.   
With sincere regards

Dr Naif AlOmairi
Head of the Dept.of Medicine 
College of Medicine Taif University KSA

Cold drops of sweat in a young adult.!!!!

Clinical scenario
The dawn was breaking and a 46 years old gentleman presented to the ER complaining of severe chest tightness of 1-hour duration. The chest pain was retrosternal, pressure like associated with SOB and vomiting. It radiated to his left shoulder and was not relieved by rest, There was no palpitation, LL edema, orthopnea or PND. No fever, decrease LOC, seizure, abdominal pain or other pulmonary symptoms. He had been hypertensive for 5 years He had a history of an anginal attack 3 years ago No history of surgery
Examination:
The patient was conscious but tachypneic.
He was in obvious distress and had cold extremities with profuse sweating BP: 72/48. HR: 89. O2 sat: 98% on RA. RR: 19. T: 37.1 c CVS: S1 + S2+ 0, no murmur, no LL edema, no JVD Chest: equal air entry bilateral with no added sound Other clinical exams were unremarkable
Investigations
CBC: Normal,K: 4.8, Na. 138,Cl : 92,Urea: 54,Cr: 1.1 ECG: rate: 82, rhythm: regular, axis: normal, normal QRS complex, ST elevation in AVR and V1 more than one small square with ST depression in inferolateral leads as shown in Fig.1

Fig.1 ECG of the index case 

Trop I : 488 ng ( normal range : <50 ng)
Hospital course :

• We received this young man in cardiogenic shock following acute myocardial infarction.
• The patient was directly shifted to the critical care area within the ER and cardiology team contacted to activate Cath Lab.
• Meanwhile, the patient was started on NS fluids in both arms and nor-epinephrine was kept standby till cardiologist arrived at the ER.
• Vitals continued to be compromised. BP 65/40
• The Cath lab was busy as another 2 cases were going on there.
• The cardiologist preferred to start thrombolytic therapy and he ordered morphine for pain control as well.
• The patient arrested
• CPR was done for 40 minutes
• The patient started to bleed through the EET.
• Unfortunately, the patient could not be resuscitated and was declared dead.

Teaching message
Fill the tank in cardiogenic shock before you start vasopressors and chronotropic support.
Don’t give medication which will aggravate hypotension

Contributed by
Dr.Yasser Hussain Alnofaiey Assistant professor of Emergency Medicine, Taif University Contact Dr. Yasser: Twitter

Why did he suddenly de-saturate?

Clinical scenario: 

A 56-year-old male known case of Type 2 Diabetes and hypertension poorly controlled presented with a history of sudden onset gait disturbance and slurred speech of one-day duration. 

Patient  s examination revealed Pulse 76/min regular BP180/120mm of Hg 

CNS: Motor aphasia, positive Babinski's sign, Grade 3/5 Power in both lower limbs 

The detailed neurological examination could not be carried out due to speech disturbance.

CVS: Normal, no murmur or irregular pulse 

Clinical Impression: Cerebrovascular accident 

Hemogram: Normal 

LFT/RENAL FUNCTIONS: Normal

ECG: Normal sinus rhythm 

ECHO: Normal

Fig1 CT scan showing hypodense area in Cerebellar area 

The CT scan showed hypodense zones in Cerebellum as above

Fig2 Diffusion MRI suggestive of Acute stroke 

 The diffusion MRI is shown in Fig2 Suggestive of Acute stroke

Fig 3 MR Angio:  Absence of  Right Inferior vertebral artery? thrombosed?? absent  

Day 2 patient suddenly developed desaturation.

• He  was intubated 
• MRAngio shows occluded vertebral  artery and its branch PICA ( shown by the arrow in Fig3)
• Affecting the Medullary region leading to the respiratory center involvement explaining sudden desaturation 

Final Diagnosis: Acute Left PICA territory infarction 

• Management: Patient was initially managed in ICU and later shifted to the ward and is improving 

Click here for further Reading

This case was contributed by 

Dr.  Yahea Alzahrani

Consultant Neuro Radiologist 
Assistant Professor 
College of Medicine Taif University 

Taif Saudi Arabia 

Pericardial effusion unmasked SLE in a psychizophrenic adult male

Clinical scenario:
A 27-year-old male suddenly developed aggressiveness and violent behaviour within 24 hours while at his workplace. The patient had no insight into his illness and was brought to the local psychiatric hospital by his colleagues where he was admitted and treated for acute mania with electroconvulsive
therapy (EST) and antipsychotic medication. After a few days, the patient was discharged on anti-psychiatric medications. Six months later while on antipsychotic medication he developed fever and lymphadenopathy. He was admitted to another hospital where a lymph node biopsy revealed follicular hyperplasia, without any abnormal cell.  The patient’s HBV, HCV and HIV tests were all negative. The patient developed progressive weakness, anorexia, malaise, and virtually become bed bound. He was admitted to the King Abdul Aziz hospital in Taif, Saudi Arabia where the examination revealed pallor, generalised lymph-adenopathy, palmer rash, alopecia and mouth ulcers.
On evaluation, he had significant proteinuria, and ANA dsDNA was positive. The patient had mild pericardial effusion and mitral regurgitation (MR ++ noted on echocardiography).
Lupus anticoagulant was negative. With all these signs and symptoms, the patient was diagnosed with SLE and was managed with steroids which he tolerated well and improved progressively on the follow-up investigations. On follow up, proteinuria persisted and a kidney biopsy showed class IV lupus nephritis.  The lupus nephritis was treated with pulse cyclophosphamide and later the patient was started on tablet Mycophenolate.
 The patients showed improvement in that his haemoglobin levels increased (Shown in Table 1) and he was clinically well and mobilising. Two years on, on follow up the patient rejoined work and no longer required his anti-psychotic medications.
Click here to read further: British Journal of Medical Practitioners

Communication skills in Clinical practice

Dear Students
Much of the art of medicine lies in communication.
Doctors who communicate well are able to identify a patient's problem more rapidly and accurately, while their patients benefit from a better understanding of their condition and its management.
Good communication skills are the most important part of being a good doctor.
These should always include:

• maintaining good eye contact
• checking the patient's prior knowledge or understanding
• active listening
• encouraging verbal and non-verbal communication
• avoiding jargon
• eliciting and addressing the patient's agenda
• ability to discuss difficult issues
• going at a pace that is comfortable for the patient.

Always sum up the history and ask the patient to add or change 

Show empathy and sympathy, we are not Roberts 

 

Watch this video to learn good communication skills during a patient encounter in practice or in your exams

Best !!! 

Glimpses of OSCE at College of Medicine TU.KSA

The Department of Medicine wishes all our outgoing 6th-year students the Best of Luck!

Abdominal tuberculosis Revisited

Clinical scenario :
A 23-year-old male presented with fever and malaise of 2 weeks duration.Patient was put on inj Ceftriaxone 1.5 gm bid for 15 days by a physician but the patient had no relief in his symptoms and presented to our centre.
On examination, he was conscious, oriented and hemodynamically stable. There was no icterus or lymphadenopathy. JVP was normal.
Chest and CVS were normal.
Abdominal examination showed a doughy feel of the abdomen and shifting dullness was positive.
Investigations:

• The patient had normal hemogram but ESR was raised to 55mm for the first hour
• LFT was normal.
• Ultrasound abdomen was done which revealed moderate ascites with mated lymph nodes
•   The ascitic fluid: Straw coloured with protein >3g/dl, and total cell count of 150-4000/ μl, consisting predominantly of lymphocytes. 
• ADA was  strongly Positive 
• CT scan abdomen: Confirmed mated lymphadenopathy Ascites

Hospital course: Patient was started on Antitubercular treatment and his fever settled and is following our OPD for the last 6 months now.

Teaching message:

• Practice evidence-based medicine.
• Evaluate before starting antibiotics
• Peritoneal tuberculosis is the most common presentation of abdominal tuberculosis and includes the involvement of the peritoneal cavity, mesenterium and omentum .
• The lymph node disease pattern is variable at CT, most frequently demonstrating lymph node enlargement (40-60%) with hypoattenuation in the centre and hyperattenuation in the periphery, after intravenous contrast injection, which is typical but not pathognomonic of caseous necrosis 
• The ascites in TB shows serum-ascites albumin gradient is less than 1.1 g/dl. The yield of organisms on smear and culture is low. Staining for acid-fast bacilli is positive in less than 3 per cent of cases. A positive culture is obtained in less than 20 per cent of cases, and it takes 6-8 wk for the mycobacterium colonies to appear.  

• Lymphoma, metastasis, pyogenic infection and Whipple's disease are the main differential diagnoses.

Fig A & B CT scan showing abdominal Tuberculosis lymphadenopathy 

• Tuberculosis (TB) is a re-emerging global emergency which is further complicated by AIDS/HIV infection and the use of immunosuppressant drugs.

• The value of laparoscopy in the diagnosis of abdominal tuberculosis is well established. Some authors consider it as the most specific diagnostic test for abdominal TB with its advantage of histological confirmation.

Fig 3 Laparoscopic view of Abdominal Tuberculosis 

Further reading click the Link:   A Mohamed, N Bhat, M Abukhater, M Riaz. Role of Laparoscopy in Diagnosis of Abdominal Tuberculosis.. The Internet Journal of Infectious Diseases. 2009 Volume 8 Number 2.

This case was contributed by 
Dr Mir Ghulam Mohammad
Senior Consultant Anesthesiologist 
& Intensive care Physician
J&K Health services Kashmir  

Segments of the Liver revisited

Contributed By:

Dr. Mohammad Saleem Itoo,
Associate Professor Postgraduate Dept . of Anatomy
Government Medical College Srinagar.
J&K,190010
Email : dr.saleem68@gmail.com

An unusual cause of shortness of breath in a young male

Clinical scenario:

A 30-year-old male presented with a history of shortness of breath of one-day duration. On examination, Patient was conscious, oriented hemodynamically stable. There were scattered crackles bilaterally on auscultation.CVS and Abdomen exam was normal 

 One year before the current presentation, he had noticed painful swelling of his right testis. He had consulted a doctor but didn't follow the advice.

An X-ray chest in ER taken is shown below 

Fig 1 X-ray chest showing canon balls  

There was a hard firm swelling in the right testis and an

Ultrasound of the testis showed  diffuse hypoechoic mass suggestive of a neoplastic lesion

Fig 2 Testicular mass 

Cannonball metastases:

• Multiple well-defined lesions in both lungs are called cannonball metastases due to their large, round appearance. 
• This pattern is the common manifestation of a metastatic disease. The rich vascular bed of the lungs is hospitable to tumor emboli. 
•  In some patient, however, a history of a primary cancer is lacking at initial presentation. Such a sole presentation of cannonball metastases is classically seen in germ cell tumor, choriocarcinoma, and endometrial cancer.
• It is noteworthy that these cancers are sometimes described as human chorionic gonadotropin (hCG) expressing tumors as well. Other than pregnancy, hCG may also be secreted abnormally by certain tumors, particularly in gestational trophoblastic diseases, germ cell tumors, pathological growths of the bladder, uterus, testicular and epithelial cancers. 
• Other causes are :
• renal cell carcinoma
• less common primary tumors:prostate carcinoma,synovial sarcoma, endometrial carcinoma

Click to read Further :Lung metastases Imaging

This case was contributed by

Dr Mohamed Elsaid Matter 

Consultant Pulmonologist 

King Abdul Aziz Specialist Hospital

 Taif KSA 

Every minute counts !

Per-operative course :

A 35 years old female with no comorbid illness having normal investigations ( ASA class 1st) was to undergo exploratory laparotomy in a secondary care hospital.

• The patient was anesthetised and the surgery was started by the team of surgeons
• After half an hour she developed cardiac arrest on the operation table.

• The anaesthetic agents were stopped 
• The cardiac massage was started and continued for 4 minutes while she was intubated and on 100% oxygen.
• But there was no response to  CPR.
• An open thoracotomy was done immediately. 
• A direct cardiac massage was done from the apex to the base of the heart. 
• There was an immediate response and the heart restarted beating. 
• The planned surgery was carried out successfully.
• The sternotomy wound was closed.
• Patient discharged home in a stable condition.

Teaching message: Every minute counts to prevent Brain damage while doing CPR

 

Further reading click the Link:  Thoracotomy versus closed chest compression

This case was contributed by 
Dr Mir Ghulam Mohammad
Senior Consultant Anesthesiologist 
& Intensive care Physician
J&K Health services Kashmir