Sunday, March 25, 2007
Yay, the last exam's over!!
We taken to 2 cases by 4 female examiners, but they were exceedingly nice. The first 2 had rather strict faces though, although I had the impression that they were trying to look strict rather than being really strict. So here's my paeds cases:
1. Spastic diplegic cerebral palsyWalked into the room to find a 17-year-old guy as my patient, and his mom sitting by his side. Oh
WOW. Thanks so much, Mommy and Patient! Examiner said, "Please examine his gait, and proceed from there". Hmmmmm ... Duchenne's? CP? Spinal muscular atrophy? Spina bifida?
OK, I admit I got the gait wrong. The diplegic gait really looks like a waddling gait what! Redeemed it by saying that I didn't see Gower's Sign. Nods and smiles. The patient was wonderful. He did everything himself - walked to end of corridor, turned, came back, stood on 1 leg, squatted and stood up. Talk about good priming!!
It was only during the neuro examination that I managed to get my diagnosis in order. Heehee ... scored a little I guess, I noticed an ADULT tendon tapper on the table, so made a show of putting away my paeds tapper and using it instead, at which they smiled appreciatively and said, "Yes, use the adult one, that's right." Typical upper motor neuron signs with clonus, increased tone, brisk reflexes. Pretty proud of myself actually, for once I did the reflexes nicely and sleekly. Strangely though, he had a bit of proximal muscle weakness. Was about to do sensory examination when examiner 2 asked, "Why do you want to test for sensation?". Mentioned cord transection as another possible cause of diplegic spastic paralysis and that I can gauge transection level by dermatomal distribution. Nods and smiles. Okie! =)
"So what do you think he has?"
"Mdm, this patient has spastic diplegic cerebral palsy as evidenced by the (blah blah blah blah) upper motor neuron signs. He retains good functionality as he has good gait and posture control, and does not need any ambulatory devices that I can see."
"What is the most likely cause?"
Most commonly due to perinatal asphyxia, but went on to categorise into antenatal (intrauterine infection, placental insufficiency) and post-natal (non-accidental injury, trauma, intraventricular bleeding, meningoencephalitis)
"What kinds of intrauterine infections are you concerned about?"
TORCH infections- TOxoplasmosis, Rubella, Chlamydia .. then faltered a bit for the "H" - FACK, it's Herpes simplex!! They looked amused at me faltering and decided to spare me.
"So do you think it might be TORCH infections in this case?"
No, because the patient will also have accompanying deafness and blindness etc.
Bell rings, I went to the next case.
2. Cushing's SyndromeAlas! OMG, I have never - NEVER - seen a Cushing's as florid as this. Remember purple abdominal striae? This young girl had striae on the arms and legs as well! Examiners were 2 women, 1 was Dr. L.Shek (score!!) and the other, a goodly elderly lady who had such a kind face I wouldn't mind her being my aunt at all. Just be nice and generous with the marks, can? It wasn't all that smooth and sleek, but for one wild moment I DID think of ichthyosis and other strange, rare skin disorders.
"Please look at this young lady's lower limbs, and proceed from there."
At first glance, my first (shocking) thought was ichthyosis! I dumped that thought and made a brash statement of "I see striae distributed blah blah blah" and they nodded, so I went on to describe the textbook stuff - central obesity, rounded facies, abdo striae, but no thin skin, no supraclavicular and interscapular fat pads. As I was looking at the back for the interscapular pads, the Nice Elderly Examiner (NEE) pointed to her neck, and I was like oooooh ... acanthosis nigricans! Also noticed some gingival hypertrophy, but I think the examiners missed that cos they actually came to have a look. Damn. I tried examiner-baiting by saying, "I also see florid gingival hypertrophy" and was waiting for them to ask, "what are the causes of gingival hypertrophy?". Grrr .. that never came.
"What do you think this girl has?"
Cushing's syndrome, most likely cause being exogenous steroid use. (Although for one very, VERY heart-stopping moment I thought she appeared a little dark and thought ... holy ****!! Addison's Disease requiring steroid replacement????!???!?!!!? Then I realised ... Oh. She's Indian.)
"What else do you want to look for?"
Frequent infections, oral and perineal candidiasis, skin wounds.
"Please proceed"
Nil. No candidiasis of the mouth, was told not to look at the perineum (Duh ..)
"Anything else?"
I'd like to look for a reason why she's on such high-dose steroids. So I offered respiratory examination for asthma, and had to be prompted into systemic lupus and nephrotic syndrome. Noted some ectopic patches all over, so I brashly suggested that she may be using steroids for very severe dermatitis. Examiners' eyes bulged so much out of their sockets that they were in danger of falling to the floor, so hastily changed my tune and said that it is, however, highly unusual not to use topical steroids instead.
"So what do you think is the most likely cause?"
Nephrotic, since:
1. No malar rash of SLE
2. No wheezing of asthma, and anyway it's very rare to use that much steroids in asthma
But mentioned there was no oedema at this time, it could be steroid-dependent nephrotic syndrome.
Then prompted into other things ... urgh.
"She now says she can't see clearly .. so - "
OOOOOOOPS. I'd like to check for cataracts.
"How would you do that?"
Using the fundoscope for loss of red reflex, and also a slit lamp biomicroscope to identify the type of cataract.
"So what would you be concerned about in the long term?"
Shiiiiiit. Forgot height and weight. So said that long-term use can cause growth problems, offered to take height and weight, and insulin resistance, and osteopenia.
"What bedside tests can you do to screen for these?"
Height and weight, urine dipstick, capillary blood glucose, blood pressure.
The NEE turned to Dr. Shek and whispered, "You have any more questions?" She shook her head, and I was herded out of the ward. To my shock and horror, I was extremely early. The bell hasn't rung, and I felt so insecure I asked one of the nurses if the other students in that room also took such a short time ... she reassured me that that's the case. Phew. Once again, massive diaphoresis, was offered drinks and tissue by the amused-looking nurse who repeatedly asked me to calm down.
****
In all, the 4 ladies were exceptionally nice, all of a sudden my fondness for paediatricians has increased somewhat. Done and over with, although very nasty rumours have been flying around about sigh ... nevermind. Just hope for the best! Slightly disappointed that I didn't get a cardiac or developmental assessment case, and that all the stickers, toys etc that I brought weren't put to good use. My patients were like 17 yrs and 13-14 yrs old!
Wenky
10:52 AM
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