When Worrying Too Much is a Problem, Literally.

Interesting cases today (as thinking exercises for to-be final year students):

1. Middle-aged woman presented with clear mucus coughing + SOB, LOA, LOW for 2 weeks 3 days, associated with pleuritic chest pain, night sweats and shivers. On observation, her eyes are opened extremely wide, face is pale but pink conjunctiva, very anxious, a bit tachypneic (20-22 breaths per minute). But the best part is that despite dyspnea, her SpO2 was 100% under room air. While clerking further she complained of cramping sensation of the fingers. This is her second visit to ED. Spot diagnosis?

2. Middle-aged man with no known history of medical illnesses presented with sudden severe headache, giddiness, nausea and vomiting since 30 minutes. No SOB or chest pain. Lungs clear. ECG and capillary sugar were normal. Similar episode a few months ago, resolved on its own. Differential?

3. Ever seen the pain of a patient with classical renal colic? Writhing about moaning in pain, hand at loin. What should you do first after allergy screen?

4. Elderly woman with a history of hypertension for about 10 years presented with fever and cough for 2 days, associated with shortness of breath, pleuritic chest pain and disorientation. Examination revealed edema up to both knees, coarse crepitations in middle to lower zones bilaterally, with displaced apex beat. Provisional?

5. 2 month old baby boy presented with history of 1 week on and off fever and cough, rapid breathing, difficulty in feeding. Examination revealed tachypnea, subcostal retractions with rhonchi and crepitations. Impression?

6. 7 year old boy complained of left testicular pain. We didn't manage to see the patient, but what is the no 1 diagnosis to be assumed until proven otherwise?

7. Classical description of a dengue macular rash?

1. Hyperventilation with underlying pneumonia, probably CAP. The patient was so anxious about her pneumonia that she developed respiratory alkalosis during clerking, instantly relieved by breathing into a bag. Radiograph showed perihilar and lower zone haziness. Sputum for AFB negative.

2. Rule out cardiac causes. Always check the vital signs. This patient had hypertensive emergency (encephalopathy) revealed by taking the BP (I purposely did not reveal it the above even though it was obvious when checking the BP). Lowered the BP with oral nifedipine down to 140 systolic and he was completely back to normal.

3. Just give her analgesia and she will "shut up" (a good thing). From 10 to 3 pain score instantly.

4. CAP, to rule out decompensated CCF.

5. Bronchiolitis probably complicated with secondary pneumonia.

6. Torsion torsion torsion. Remember the location of both testes relative to each other (which one is higher) and correlate with the presentation of patients. It's clinical embryology? What if the left is higher than the right?

7. White islands in a red sea. Don't forget how to perform a Hess's test and it's interpretation.