Cases sent by students and response by teacher:

Case 1;
 
We did CNS examination on a young gentleman known HIV patient and IVDU who has a left hemiplegia.
 
on examination, patient looks alert,concious but cachexic.he has an IV canulla inserted at the medial aspects of right lower limb and patients was using diapers.there is pallor,oral hygiene is poor,multiple bruises and hyperpigmentation on the extensor aspect of his limbs.there is also present of tattoo on his right shoulder and multiple injection scars due to previous history of self injections at the medial side of his right upper limb.on motor examination,the left upper and lower limbs are paralysed,power grade 0,reflexes are present,and babinski's sign was positive,patellar and ankle clonus cant be elicited.on examination of the right limbs ,muscle power of upper limb was 4/5 and lower limb was 4/5 too.reflexes are normal and babinski's sign was negative.

Response -Please tell us what have you thought of as possible causes for right hemiparesis in an HIV postive patient. Try to find out what diagnosis has been made by the treating unit. Which were the investigations that were helpful in making the diagnosis?

case 2;
 
we went to see the patient of multiple sclerosis.on eye examination,visual acuity was 4 foot away for both eyes as she has blurred vision.

she was having upper limbs hypotonia,muscle power grade 4/5 of both sides and normal reflexes.meanwhile her lower limbs were hyperreflexia(it bends even when we tried to take off her socks) and hypertonia.patellar and ankle clonus are present on both sides,while babinskis sign were positive too.her bed sore has almost healed.there were cerebellar signs elicited like shooting of finger nose test.dysdiadochokinesia was not seen and knee heel test cant be performed as she has hyperreflexia of both lower limbs.

Response -The dysdiadochokinesia may be false positive as one needs to have normal power to test for co-ordination. She looks more moribund than the last month with her cachexia and alopecia. Possibly it’s because of the immunosuppresants that she is receiving. Do find out what drugs she is recieving and what are the other side effects they are producing (on her blood count, biochemical parameters etc). She is one of the cases for the chronic paralysis research group. Find out the evidence base regarding the efficacy of the immunosuppresants she is receiving in terms of treatment outcome for the disease (the cause of her chronic paralysis). Like tolerating all these side effects that you can see on the general survey would still be worthwhile if her neurodeficits improved. We also need to follow her up closely for this so don’t forget to take her phone number and complete address. Also take informed consent from all the patients (as it would be necessary for putting all this online even if anonymity is maintained—translate the informed consent form into Malay).


case 3:
a 62 yr old female was admitted 9 days ago with chief complaints of abdominal swelling.....she is a known case of diabetic....she has been
having this problem for 6 months now....the onset is gradual and it has been increasing in size progressively......4 months ago she had episodes of constipation and abdominal pain.....following which she went to the hospital and was admitted there...and fluid was taken out of her abdomen...she was relieved for a while and then her problems started again.....she has fever off and on...she also has swelling of her feet......

she has no breathlessness, no cough, no wheeze, no chest pain, no right hypochondrial pain, no decrease in urinary output, no nausea and vomiting, no wieght loss......

on examination, patient is alert and co operative......she moderately built and nourished.....positive findings are she has icterus and pedal edema..... her pulse was 80 beats/min......he bp was 110/70mmhg, her respiratoty rate was  18 breaths/minute and she was afebrile at the moment.....

on abdominal examination, she has a distended abdomen with full flanks.....no palpable mass or tenderness....she has shifting
dullness...normal bowel sounds heard....

other systems were all normal.......

Response —From your presentation it is evident that she has ascites with jaundice that also suggests that it is perhaps because of a chronic liver failure. However what is the cause of her chronic liver failure? Try to find out and let me know. Also look for possible ways in which this can be treated.

case 4:
an elderly gentleman came to the hospital with chief complaints of breathlessness......he is a known diabetic for 5 yrs and hypertensive for 2
months...he is also a case of known asthmatic.....this admission was due to the acute exacerbations of his asthma....he has tingling sensation on his feet and hand...there was wheezing at the time of admission...

there is no history of cough with expectoration, no history of pnd or orthopnoea, no chest pain, no nausea and vomiting, no fever and fatigabily......

on general examnation, everything was normal..... all systems were normal.... on cns examination, we found that patient has lost sense of pain over the  medial 2/3 of his toes on the right side and at the great toe on the left side.....vibration sense was also lost.....joint position sense was
normal......his cranial nervers were normal......his motor system was normal.....

Response—Suggests that he may have developed early peripheral neuropathy due to diabetes. However how can you assume that he has asthma just because he tells you. What is the most important feature in his history that tells you it is asthma and not COPD?

Rakesh