1. Causes of CCF-maz
2. signs + symptoms-explanation-saree
3. pathophysio- afterload, preload, hormonal changes that occur, BNP-yazid
4. Ix of CCF- echo, ECG etc- alvin
5. Management- mx of acute pulm oedema in ED - christine
6. Mx- chronic CCF- include all diff drugs used in HF- chris

Read about Ix for young patient with HTN?

1. Different between nephritic and nephrotic syndrome? (chris)
2. Primary cause + pathophysiology glomerulonephritis (christine)
3. 2^nd cause + pathophysiology glomerulonephritis (saree)

· Post strept infection (rheumatic fever)

· DM (due increase filtration à protein deposition)

· Lymphoma + leukemia

4. Investigation of glomerulonephritis? (Alvin)
1. Ix to further Dx – classify nephritis
2. When is biopsy done? (indication)

i. Ix before biopsy

ii. Procedure

iii. Contraindication

iv. Precaution

3. Urinalysis

i. How Dx nephritis?

4. Ix to rule out 2^nd cause

5. Management (maze)
6. Brief systemic vasculitis (yazid)
1. Types (large, medium, small)
2. manifestion

Lai is a 42 year old Chinese lady who works as a factory worker (quality check) in Singapore. She was referred to HSA a week ago from Johor Specialist on a 2 month history of swelling in her legs, face and abdomen.

Presenting complaint

Lai presented to the clinic with a sudden onset of swelling in her legs and mild fever on 1^st February while she was on a road trip to Penang.

HOPC

Progression: migratory swelling from legs to trunk and face over a period of 2 weeks. In addition, her weight increased from 62kg to 71kg.

Aggravating or alleviating factors: none mentioned by the patient

Associated symptoms:

• Loss of appetite not associated weight loss but weight gain, started with the onset of oedema. She only takes one meal a day instead of 3 meals per day.
• No change in urinary habits( no oliguria, anuria or change in frequency).
• Frothy urine one week after onset of oedema.
• Disturbed sleep at night, unable to sleep throughout the night, she wakes up around early morning and goes back to sleep near morning. She is not woken up by SOB or need to go to the toilet.
• General fatigue

Time line

1) went to GP for oedema of legs (1 feb)

2) blood test showing SLE positive results

3) admitted to JS by her GP

4) JS performed a kidney biopsy on her 12/2/08

5) After the biopsy, she complained of haematuria, dysuria, feeling of swelling and mild sharp pain in her kidneys that went away after 2 days.

6) Admitted to H SA on 28/ 3

Rheumatology??

Neurology??

SLE

No other symptoms of SLE (hair loss, photosensitivity, rash, oral ulcers, pain, arthritis, bleeding tendency)

Blurring vision?

Numbess? + weakness?

* important –ve findings should be include in HOPC

Cardiovascular systems review:

Exertional dyspnoea on walking 100m( from one end of the PP1 ward to the other) since hospitalization in HSA.

Leg swelling on both legs (bilateral oedema until mid tibia)

No orthopnoea or PND.

No claudication

No angina, or sweating

No syncope

Respiratory Review

Mild non productive cough ( started 2 weeks ago), through out the day

No hemoptosis

No wheeze

No facial pain

No pleuritic pain

Mild intermittent 1 day fever concurrent with onset of leg oedema

GI

Loss of appetite

No other GI symptoms

Past medical Hx

• No history of atopy (allergy rhinitis, conjunctiva, asthma, migraine)
  high BP (5 years ago)

– on regular checkup every 3month on antihypertensive medication

– ask about investigation of HTN (maybe 2^nd cause)

§ possibility of involvement of renal during onset

• Stop recently, not staying in Singapore
• Borderline cholesterol
• Borderline uric acid
• No past hospitalization, or trauma.
  

Drugs/allergy/CAM

· Traditional Chinese meds – 2 pills at Penang, stopped taking the pill because it had no effect on her oedema

· Herbal remedies for general well-being

o last dose was ½ year ago

· On OCP since her visit to the obstetrics and gynecology regarding her menstruation. Been taking the Pill for more than 5 years. She cannot remember when she started on it.

· -antihypertensive

· -prednisolone

Allergies:

• No drug allergy
• Allergic to mangoes, rambutan and durian. Feels hot and suffers from a sore throat after consuming the fruits.

Last Menstrual period

Lastmonth

Regular since on OCP

Irregular since menarche (age 14)

Once per 3 month or every few months

Went to OnG – prescribe OCP to regulate her menses.

Family Hx

Mother (70) – hypertension, on antihypertensive

Father (age 75 ) – skin cancer on face 2 years ago, got removed surgically,

Siblings: 2 /12 – no known illness, no history of atopy

Social/occupation

Does not smoke

Passive smoking at workplace (during lunch break)

Doesn’t drink

12hour shift – 7am – 7pm

QC – not exposed to chemicals

Nature of work: involves her standing at the production line and checking the microchips for correct assembly

dDx

1. Chronic renal failure 2^nd to hypertension/nephritis
2. nephrotic syndrome 2^nd to glomerulonephritis
3. CCF x
4. chronic liver failure x

Examination

General Inspection:

Alert, comfortable, hydrated, not in respiratory distressed

Vital signs

Pulse: 112 bpm, regular rhythm, strong in volume

RR: 12 breaths/min

T: 37⁰C

BP: 160/110

No elevated JVP

Hands

- Capillary refill normal

- Wasting of Thenar and hypothenar eminence of both hands

- proximal muscle wasting, no weakness

- no flapping tremor

Neurological Examination?

* peripheral neuropathy

Face

- No signs of anemic, central cyanosis, jaundice

- signs of hirsutism

-puffy face

-no malar or discoid rash

-no oral ulcers

-no paraorbital oedema

Chest

- Heart

o Apex beat not displaced

o Audible S1 and S2

- Lungs

o Symmetrical chest expansion

o Dullness on percussion, reduce vocal resonance, reduce breathing sounds at lower L lung

- Abdomen

o Distended

o No signs of tenderness or guarding

o No palpable mass

o +ve shifting dullness test

o Normal bowel sound

- Leg

o Pitting edema up until mid tibial

radial-radial delay?

Radial-femoral delay?

Signs of systemic vasculitis?

*Fundoscopy (microcirculation)

Examine 2^nd cause of HTN

Emily, 27, manager

PCx
Visual Sx L eye (blurring), colour vision less intense than normal
Mild pain on movement

PHx
UTI?
Urinary urgency
Incontinence (10 days) – 15 years ago

Tendency to drag left leg
Frequent trips + new fall

Social
Nonsmoker
Drink few glass (weekends)
Marijuana (during teenager)
OCP

Ex
Blurring of L optic disc margin
Disc pallor
afferent papillary defect (L)
deep tendon reflex (brisk) at L lower limb
plantar reflex (extensor) à upper motor neuron lesion?

MRI scan
Brian
T2 hyperintensity of anterior L optic nerve
Small T2 hyperintense lesion in corpus collosum + periventricular white matter
Small in T1 image

Thorax
Non-specific abnormality at T4 left side

CSF
Oligoclonalprotein bands (-ve in serum)

TASK
Multiple Sclerosis
a. Clinical presentation (saree)
i. Patho
b. Epidemiology (more common where? Who?) + Psychosocial (Chris)
i. Patient’s reaction
d. Crititeria for Dx (Alvin)
i. Communicating skill
e. Investigation (yazid)
i. MRI
ii. Oligoclonalproten bands
f. Management + Palliative care
(Christine)
g. Complication + Prognosis + Progression (Maze)

Skin cancers

1. Aetiology, incidence in Malaysia + Aus, Classification (Sareee)

2. Basal cell carcinoma - Clinical manifestation and management??

3. Squamous cell carcinoma- Clinical manifestation and management (Yazid)

4. Melanoma - Clinical manifestation and management ??

5. Skin biopsies- Types..Maz

6. Describe lesions-- Alvin


Really sry.. didnt record the task.. Plz fill in those question marks.

- An exaggerated ↑ in blood sugar following a meal.
- people who don’t have diabetes, pancreas secretes some insulin all the time. It ↑ its output as blood glucose ↑ following meals.
- people with Type 2 diabetes, the pancreas can be slow about secreting insulin in response to a mealà to postprandial hyperglycemia
- an independent risk factor for the development of macrovascular complications.
- normalizing post-prandial blood glucose is more difficult than normalizing fasting glucose.
- poses a challenge to people with diabetes striving to maintain near-normal blood sugar levels.
- Multiple injection regimens and insulin pumps provide flexibility in handling the challenge.
- A person can take regular insulin ½ to 1 hour before eating so that the insulin peak and glucose rise coincide.

tests used for diagnosis:

1) fasting plasma glucose test (FPG)

o measures your blood glucose after you have gone at least 8 hours without eating.

o used to detect diabetes or pre-diabetes.

o the preferred test for diagnosing diabetes due to convenience

o most reliable when done in the morning

Plasma Glucose Result (mg/dL)	Diagnosis
110 and below	Normal
110 to 125	Pre-diabetes (impaired fasting glucose) -more likely to develop type 2 diabetes)
126 and above	Diabetes*

Table 1. Fasting Plasma Glucose Test

*Confirmed by repeating the test on a different day.

2) oral glucose tolerance test (OGTT)

o measures your blood glucose after you have gone at least 8 hours without eating and after you drink a glucose-containing beverage. (75 grams of glucose dissolved in water; 100 grams for pregnant wome)

o blood will be taken before drinking glucose-containing solution, and again every 30 to 60 minutes after drinking the solution. The test takes up to 3 hours.

o can be used to diagnose diabetes or pre-diabetes, gestational diabetes.

2-Hour Plasma Glucose Result (mg/dL)	Diagnosis
139 and below	Normal
140 to 199	Pre-diabetes (impaired glucose tolerance)
200 and above	Diabetes*

Table 2. Oral Glucose Tolerance Test

o For diagnosis of gestational diabetes, blood glucose levels are checked 4x during the test.

o If blood glucose levels are above normal at least twice during the test, you have gestational diabetes.

When	Plasma Glucose Result (mg/dL)
Fasting	105 or higher
At 1 hour	190 or higher
At 2 hours	165 or higher
At 3 hours	145 or higher

Table 3. Gestational Diabetes: Above-Normal
Results for the Oral Glucose Tolerance Test

3) random plasma glucose test (RPG)

o doctor checks your blood glucose without regard to when you ate your last meal.

o random blood glucose level of 200 mg/dL or more + presence of the following symptoms, can mean that you have diabetes:

· increased urination

· increased thirst

· unexplained weight loss

· Other symptoms include fatigue, blurred vision, increased hunger, and sores that do not heal

o This test, along with an assessment of symptoms, is used to diagnose diabetes but not pre-diabetes.

o Positive test results should be confirmed by repeating the fasting plasma glucose test or the oral glucose tolerance test on a different day.