Dr. Esther Tsang
August 2011
Case 1
 50 year old lady presented with acute onset of
shortness of breath this morning.
 This was preceded by one episode of chest pain and
vomiting.
 She has had diabetes mellitus for the past 10 years.
 What other history would you ask for?
 What are your differential diagnosis?
 On examination, she was breathless with a RR of 20
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bpm, HR 120 bpm, BP of 98/60, SPO2 89%.
Her peripheries were cool to touch and her pulse was
thready.
JVP was raised at 10 cm.
Fine crepitations were heard up to the mid zone in
both lungs.
Examination of the heart revealed a gallop rhythm.
 Explain the physical signs.
 What does the JVP reflect?
 How do you measure the JVP?
 What investigations would you order?
 ECG is as follows :
 Identify the P wave, QRS complex, ST segment, and T
wave.
 What is the diagnosis?
 Describe the changes in the CXR
 Name at least 5.
 So what is your full diagnosis?
 How would you manage her?
 What do you do for her poor oxygenation?
 What if her blood gas is as follows :
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pH 7.31
pO2 9 kPa
pCO2 7 kPa
HCO3 28 kPa
Interpret the blood gas.
What would you do?
 Since she is hypotensive, do you give fluid challenge?
 Your medical officer asks you to monitor the central
venous pressure and the PCWP.
 How are these measured?
 What is the difference between the two?
 What medications can be given to reduce pulmonary
congestion?
 After all you have done, her blood pressure drops
further to 80/60mm Hg.
 Do you start an inotrope or give fluids?
 Explain your decision.
 If you were to start an inotrope, which one would be
your choice and why?
 What parameters would you monitor while
resuscitating this patient?
Case 2
 65 year old male, with known CRF.
 Last seen in nephrology unit in June 2011. Counseled
for dialysis but refused.
 He presented with increasing shortness of breath and
bilateral pedal oedema of 2 weeks duration.
 He also had epigastric pain.
 He has been taking some medications for his knee
pains for the past 3 weeks and some traditional chinese
medicines to improve his kidney function.
 Renal profile done in casualty are as follows :
 Na 130
 K 6.4
 Urea 42 mmol/L
 Creat 465 mmol/L
 Minimal hemolysis noted.
 What other history would you ask for?
 What painkillers might he have taken?
 Can you explain the epigastric pain?
 Give some examples of nephrotoxic drugs.
 You proceed to physical examination and find the
following :
 BP 220/120 mm Hg
 HR130
 SpO2 88%
 T afebrile
 Pallor
 Pedal oedema up to knees, pitting.
 Lungs – crepitatations up to the mid zones.
 You examine his fundus and find the following :
 Explain the physical findings.
 Describe the fundus.
 What are the changes of hypertensive retinopathy?
 How is this useful in determining your management?
 What other investigations would you request for?
 FBC as follows :
 TWC 12.0
 Hb 7.5 g/dL
 Plt 650
 What could be the causes of his anaemia?
 How do we determine the cause of his anaemia?
 ABG as follows :
 pH 7.30
 pCO2 3.9kPa
 pO2 10.0 kPa
 HCO3 16.0 mmol/L
 How do you interpret the blood gases?
 ECG
 Read the ECG. What are the abnormalities?
 CE was normal.
 What is the cause of the ECG changes?
 What is the complete diagnosis for this gentleman?
 How would you manage this patient?
 Write your management plan in detail.
 What are the indications for dialysis?
The end.