Gout and Cushing....how are they related?

This was a case of a gentleman I saw in MOPD few years ago. He had these changes to his hands. 

From this picture we can see multiple tophi over the dorsum of the hands particularly over the extensor tendons as well as extensor surface of the wrists and distal forearms. There is a particularly large tophi overlying the 2nd metacarpophalangeal joint. 

You will be able to make the diagnosis of gouty arthritis just based on the above photo. However do not stop there. Go further by looking for other clues to suggest a possible aetiology of the gouty arthritis. Look for psoriatic rashes over the dorsum of hands and extensor surfaces of the limbs, also look for nail changes suggestive of psoriasis e.g. pitting nails. And also take the opportunity to look at the forearms for any arteriovenous fistulas to suggest chronic kidney disease that has progressed to end stage disease requiring hemodialysis. CKD can be associated with worsening of gout due to reduced renal clearance. 

This photo further illustrates the extent of gouty tophi deposition over the extensor surfaces and also over the elbows. 

This photo shows tophi on the ear pinna. Tophi formation tend to occur not only on the extensors but also at areas of the body where temperatures are cooler. Cooler temperatures make uric acid deposition easier. That is one reason why tophi is often seen over the distal extremities like the toes (especially the first metatarsophalangeal joint in podagra) and also the pinna. 

But take a look at the next photo. 

Take note that this patient has a body habitus suggestive of Cushing's syndrome. There is central obesity noted. There are also multiple striations over the anterior abdomen due to excessive stretching (the classical purplish or pinkish striae is not clearly seen in this photograph). And in the second photo above, the patient has a thick neck. If seen laterally, this patient also has a dorsocervical hump due to excess fat deposition (not in photo). 

The last photo above also shows multiple hyperpigmented marks on both sides of the umbilicus. Those scars are indicative of recurring injections likely from insulin therapy. Meaning this patient can be suspected to have concomitant diabetes mellitus, a diagnosis which is not surprising considering his physical appearance. This also further strengthens the diagnosis of Cushing's syndrome, of which diabetes mellitus is a feature. 

So now we have two diagnoses:

1. Chronic tophaceous gout

2. Cushing's syndrome 

So how do we tie both the diagnoses? The answer is steroids. If you are able to take one history, I would suggest you to ask about the drug history...the patient would tell you he has been visiting many clinics over the years for joint pains due to gouty attacks. During each visit he will receive a common cocktail of painkillers which often include steroids. On top of that, he also visits retail pharmacies and self medicate his joint pains by purchasing painkillers and steroids over the counter. As a result of the chronic steroid exposure, he has developed secondary Cushing's syndrome which is a complication of trying to treat his gout. Unfortunately, because of no proper follow up, he was not started on uric acid lowering treatment e.g. allopurinol. He will definitely benefit from it. 

CCE. 

The Hiatus Explained

Dear students,

First and foremost, I would like to extend my heartfelt congratulations to those who have made it through the recent MBBS Finals for Class of 2022. To those who did not make it, keep pressing on. Cross that hurdle and earn your title. 

Secondly, I would like to extend my apologies for the prolonged silence in this blog. There have been no new posts since Dec 2022. This is because I have been distracted since Jan 2023 by many issues, some of which include myself being posted to a new Specialist Hospital i.e. Hospital Pendang. With this move, I am no longer able to conduct direct clinical teachings with Final Year students. 

On top of that, I have also been busy with my new role as a visiting consultant physician in a private medical centre in Alor Setar city. 

However, teaching is a passion I have and I would still go back to teaching whenever the opportunity arises. 

Therefore, following this post, I will begin to continue updating this blog and posting relevant clinical cases and sharings to assist students in preparing for their final professional exams. 

May I request everyone who have been following this blog, to share with your juniors and encourage them to share with their juniors as well so that the knowledge imparted here will be passed on continuously.

 And also feel free to update or comment if there are any new information regarding clinical medicine or examination techniques which I may miss out. I try to keep up with the latest developments in clinical medicine, but I may fall short in certain areas. Appreciate it if we can keep each other updated whenever needed. 

If there are any requests for certain topics to be discussed, feel free to post in the comment below this post. 

To the new batch of final year students, good luck and enjoy the process. Internal Medicine is fun. 

Happy learning. 

CCE. 

JUGULAR VENOUS PRESSURE (JVP)

The JVP is an important sign to look out for especially for the CVS station.

The JVP will indicate if there is presence of fluid overload. 

Students are expected to know how to measure the JVP and to identify the characteristic features of a JVP. The height of the JVP is measured from the manubriosternal angle (Angle of Louis) until the top of the JVP pulsation. 

An abnormal JVP is a measurement of > 3cm above the manubriosternal angle. 

The JVP is best assessed in good lighting so ensure that you have your pen torch ready for extra illumination.

JVP characteristics:

1. Visible but not palpable

2. Presence of double waveform

3. It is occludable at the base of the neck

4. There is hepatojugular reflux 

CCE.

HOW NOT TO SCREW UP YOUR ABDOMINAL SHORT CASE EXAM

When you hear the bell ring and you are directed to enter the examination room, do remember your manners and greet the examiners with a brief “Good morning” or “Good afternoon”. Never before in the history of the university was there a need for a “Good night sir”. In the excitement of the exams, time can be hazy and you may lose track of it. But stay grounded and always stay in touch with reality. That is why a good night sleep the day before is essential. You don’t want to be making a fool of yourself even before the examination begins.

Upon entering the room and after you have greeted the examiners, your name will be read out and you are supposed to verify that the candidate name read is indeed your name. After which, automatically proceed to the examination bed where the patient is seated or lying down. You will find the examination instructions pasted on the table. Read it carefully and take note of the patient’s designated name and also the exam question. 

For example, the question may read “Madam A has abdominal discomfort. Please examine her abdominal system.”

A short reminder on refraining from addressing patients with “aunty”, “uncle”, “pakcik” or “makcik’. We have been doing this habitually during our day to day practice and it is customary for us as this is a respectful way of addressing our senior patients. But for the purpose of major examinations, please use the patients’ designated names instead, to sound more formal.

After reading the instructions, proceed with positioning the patient to prepare for abdominal examination. Patients should be placed in full supine position whenever possible. The head can only be supported by one pillow (maximum) but if the patient is able to tolerate without any pillow, that would be best. Remember to expose the patient adequately as well. For male patients, if they are consenting, request the patient to remove the shirt completely. For female patients, perhaps it would be better to just expose the abdomen from xiphisternum all the way down to the suprapubic or pubic symphisis region for the sake of the patient’s modesty. For the purpose of this post, I will begin the examination from general inspection, then the peripheries before the abdomen itself.

General inspection, look for:

1. Overall patient condition i.e. restless, in discomfort or comfortable. Take note of any obvious dysmorphism e.g. Cushingoid appearance etc. and last but not least any obvious skin discolorations e.g. bronze skin (hemochromatosis or iron overload conditions e.g. thalassemia), sallow skin (chronic kidney disease may suggest polycystic kidney disease or obstructive uropathy or failed renal transplant case) or jaundiced skin.

2. Look at IV drips – blood product transfusion, antibiotics, dextrose infusion etc that may give a clue to the underlying abdominal diagnosis

3. Look at CBD bag at the bedside if any – pay attention to urine colour: tea coloured urine may suggest a liver or hematological disorder, hematuria may suggest an underlying coagulopathy (possible liver disorder related)

4. Look at temperature charts at bedside if any (may indicate an infective diagnosis)

 

Hand examination (as far as possible ask the patient to lift their own hands up, you may support the hands once they have done so). Pay particular attention to the following details:

1. Finger clubbing – lower your eyes to the nail fold or Lovibond’s angle to look for loss of angle, you may also do the Schamroth window test by opposing both thumbs or index fingers together to look for loss of diamond shaped window.

2. Leuconychia – this will indicate hypoalbuminemia which may be related to the patient’s nutritional status or underlying chronic liver disease (to differentiate this from pallor, in leuconychia, the nail bed blanching will not be visible through the nails as the nails are opacified in leuconychia)

3. Nail bed colour – may hint at anemia if there is pallor

4. Capillary refill time – indicator of adequate perfusion

5. Splinter hemorrhages – stigmata of endocarditis (relevant for the abdominal station as endocarditis may be associated with splenomegaly)

6. Koilonychia – suggestive of iron deficiency – indicates underlying chronic blood loss or gastrointestinal malignancy

7. Symmetrical deforming polyarthropathies (suggestive of Rheumatoid arthritis) – may be related to the abdominal station as RA may be associated with splenomegaly in a condition called Felty syndrome

8. Tendon xanthomas – suggestive of dyslipidemia (may be associated with Non Alcoholic Fatty Liver Disease (NAFLD) or Primary Biliary Cirrhosis (PBC))

9. Intrinsic muscle wasting – indicative of nutritional status (relevant to malabsorption or chronic disease e.g. GI malignancy)

10. Hepatic flaps – hepatic encephalopathy (a sign unlikely to be seen in the exams as patients are usually well and stable). Remember to ask the patient for any pain over the wrists before performing dorsiflexion of the hands and jerking the fingers backwards to stimulate the flapping movements. 

 

Upper Limbs:

1. Bruises/ petechiea – will suggest an underlying coagulopathy or thrombocytopenia

2. Scratch marks – elevated bilirubin levels or uremia may cause itching leading to scratch marks

3. Tattoos – may indicate a risk for viral hepatitis infection

4. Multiple needle prick marks – may suggest underlying abuse of intravenous substances (risk for viral hepatitis or retroviral infection)

5. BCG scar – tuberculosis is a differential for any chronic infection in our part of the world

6. Axillary hair – look for loss of axillary hair by abducting the shoulders a little (loss of axillary hair is seen in chronic liver disease, but need to differentiate from patient’s who regularly shave their armpits)

7. Tendon xanthomas over the elbows (may indicate underlying severe dyslipidemia)

8. Arteriovenous fistulas – indicate underlying end stage kidney disease. Need to consider polycystic kidney disease in the abdominal exam station. And also look out for renal transplantation scars later on during the examination.

 

Head and neck:

1. Eyes – look for conjunctiva pallor and sclera icterus. Also observe for xanthelasma (please do not mention Kayser- Fleishcer rings as those are only seen using slit lamp examination) and arcus senilis which may indicate underlying hyperlipidemia. 

2. Mouth – angular stomatitis (indicate iron deficiency or vitamin B deficiency), glossitis (B12 deficiency), oral thrush (immunocompromised state), gingitis and caries (predisposes to endocarditis which may be associated with splenomegaly, thus making it relevant for the abdominal station), gum hyperplasia (may indicate underlying exposure to drugs like cyclosporine – an immunosuppressant that is used for renal transplant patients (relevant to the abdomen station), phenytoin (anti epileptic drug which may also be relevant to the abdomen station) or acute myeloid leukemia)

3. Neck – look for dialysis catheters, enlarged cervical lymph nodes (I would suggest examining the cervical nodes after completing the abdominal examination when you are able to sit the patient up).

Chest:

1. Spider naevi – bear in mind it can also be found in normal persons. But if there are more than 3 spider naevi found, then chronic liver disease should be suspected first.

2. Gynecomastia – look for a disc like tissue swelling in the retro-areolar region in males. It is usually tender so be gentle while palpating for it. It may indicate underlying chronic liver disease but also indicate that the patient may be on certain drugs like spironolactone. Spironolactone is a common diuretic used for patients with decompensated liver cirrhosis with ascites.

 

Abdomen:

1. Symmetry of movement with respiration – for this step I would take a step or two back and inspect the anterior abdominal wall while asking the patient to take a deep breath in and then exhaling. This movement will enable me to look for any asymmetry of abdominal wall movements. This may indicate or suggest an underlying mass.

2. Peristaltic movements – this may indicate an underlying bowel obstruction; which is unusual for the medical examination (so do not look too hard for this sign)

3. Pulsations – visible pulsations may be relevant for the abdominal examination. A pulsatile mass adjacent to the midline will alert you of a possible underlying abdominal aortic aneurysm. You will need to palpate with caution to prevent rupturing the aneurysm.

4. Surgical scars – pay attention to midline laparotomy scars, laparoscopic scars (most often at the umbilicus region and at the left or right upper quadrants), peritoneal tapping scars and appendicectomy scars. Pay close attention to subcutaneous injection scars over the periumbilical regions which may hint at regular insulin use or iron chelation therapy use (both of which are relevant to the abdominal system).

5. Visible and dilated veins – usually caput medusa (may suggest underlying liver cirrhosis with portal hypertension)

6. Cough impulse – this maneuver is to examine for possible inguinal hernias. Although this step is included in the abdominal examination, this may not be so practical for the medical station.

7. Superficial palpation – this step is to elicit any abdominal tenderness or guarding which may indicate underlying peritonism. It is highly unlikely for students to encounter such a condition in the exams, therefore, I would suggest performing this step by palpating the abdomen in 4 quadrants instead of 9 quadrants.

8. Deep palpation – this step is more important as it is intended to identify abdominal masses. Therefore it is better to perform this step by palpating the abdomen in 9 quadrants.

9. Liver palpation – begin from the right iliac fossa (RIF) and progress superiorly toward the right subcostal margin. I would recommend taking control of the patient’s breathing by asking the patient to breathe in and breathe out on your command at a pace that is suited to the student. This will allow the student to better appreciate the movement of any liver that are moving with respiration. When the patient is inspiring (breathing in), the palpating hand should be kept still awaiting the inferior liver edge to hit the hand. When the patient is expiring (breathing out), the palpating hand should move superiorly towards the right subcostal margin if no liver edge is felt. Once the liver edge is felt, the palpating hand should keep still to mark the position of the liver edge. Using the left hand, the student can feel the surface of the liver and its consistency. Remember to try to get above the mass as well to verify that the mass is indeed the enlarged liver. After that, the measuring tape should be brought out and measurements taken from the inferior liver edge to the right subcostal margin along the right mid clavicular line. Once done, the right hand can feel along the inferior liver edge to determine if its regular or irregular margins and ill- or well-defined. This is followed by percussion beginning from the right iliac fossa, gradually moving superiorly until the position of the palpable liver mass earlier. The student should take note of the change in percussion note from resonant to dull over the liver mass. Remember to also percuss the upper right hemithorax and progress inferiorly towards the right subcostal margin to identify the superior margin of the liver. Once the percussion note is dull, that is the superior margin and the measuring tape is brought out again and measurement taken from the dull point towards the right subcostal margin along the right midclavicular line. The entire liver span would be a summation of the distance from the upper margin of liver to the right subcostal margin and the distance from the right subcostal margin to the inferior margin of the liver. 

10. Spleen palpation – begin from the RIF and move diagonally towards the left hypochondrium. As per liver palpation, advance towards the left hypochondrium every time the patient expires until you feel the splenic tip hitting your fingertips. Once you’ve felt the splenic tip contacting your fingertips, stop moving your palpating hand and remain still. Use your left hand to begin feeling the surface and consistency of the spleen and attempt to get above it. Following which, draw the measuring tape again and measure the spleen size starting from the left subcostal margin along the left midclavicular line extending diagonally towards the splenic tip. Then percuss from the right iliac fossa towards the splenic mass to appreciate the change in percussion note from resonant to dull upon reaching the splenic mass. To further verify the splenic mass, percuss also the Traube’s space. In the event the spleen is not palpable, then percuss the Traube’s space. If the Traube’s space is resonant, then it is unnecessary to palpate for the spleen in right lateral position. If the Traube’s space is dull, then should proceed with turning the patient to right lateral position and then re-palpate the spleen from the umbilicus towards the left hypochondrium. Bear in mind, other causes may contribute to a dull Traube’s space on percussion i.e. left pleural effusion or a stomach mass.

11. Kidney palpation – the kidneys are balloted to determine if they are enlarged. If there is a mass arising from the right or left lumbar, the student would be required to approach it like any lump and bump i.e. palpation of the edges, surface, consistency, measurement of size in two dimensions, attempting to get above and below the mass and also percussion. A kidney mass would have overlying resonant percussion note as it is a retroperitoneal structure and the bowel loops are lying anterior to it.

12. Ascites – if the abdomen is grossly distended, it is adequate to perform fluid thrill. If the abdomen is not distended or mildly distended only, then shifting dullness percussion should be performed to identify any underlying ascites. During shifting dullness, while the patient is on right lateral position, can take this opportunity to examine the sacral area for sacral oedema and also inspect the posterior superior iliac crests bilaterally for bone marrow aspiration scars. After completing the shifting dullness percussion, it is also possible to palpate for the spleen in right lateral position if the spleen was not palpable in supine position (if Traube’s space was dull to percussion note).

13. Inguinal lymphadenopathy – I would suggest taking the opportunity to examine the inguinal nodes for any nodal enlargement after turning the patient back to supine position upon completing the examination for ascites.

 

Neck:

After completing inguinal node examination, sit the patient up to examine the cervical nodes. Avoid palpating the jugular chain nodes on both sides at the same time. This is to avoid compressing the carotid sinus simultaneously which may cause vagal syncope. 

 

Respi:

While the patient is sitting up, take the opportunity to auscultate the lungs if time permits – look for crepitation to suggest pulmonary oedema or reduced breath sounds to suggest pleural effusion. These indicate the patient may be fluid overloaded as a result of hypoalbuminemia or as a complication of underlying chronic liver disease or end stage kidney failure.

Back:

While the patient is still sitting, move inferiorly to the sacral area after auscultating the lungs. Examine the sacral area for sacral oedema as well as look for bone marrow aspiration scars over the posterior superior iliac crest region. If this step has been performed earlier, then this step need not be repeated.

 

Lower limbs:

Lastly, move to the legs and while looking at the patient, compress the bony prominences over both ankles to look for pitting pedal oedema.

 

After completing all the above, offer to complete your examination by offering to perform:

1. Rectal examination – not every patient will require this unless indicated. Per rectal examination would definitely be required if the patient is pale, and the examination is to look for melena to suggest gastrointestinal hemorrhage.

2. External genitalia examination – offer to perform this examination if chronic liver disease is in your differential diagnoses. This examination is basically to look for loss of secondary sexual characteristics e.g. testicular atrophy or loss of pubic hair which may be a manifestation of chronic liver disease or in cases of iron overload (transfusion dependent thalassemias or hemochromatosis) resulting in pituitary dysfunction.

3. The student may also offer to perform any steps which the student thinks may contribute to the diagnosis that was not done during the examination due to time constraints.

Having completed the physical examination, the next step would be to SUMMARISE the relevant findings that will lead to the provisional or main diagnosis. After which, remember to offer several relevant differential diagnoses.

Without a proper set of provisional and differential diagnoses, it will be difficult to proceed with a proper discussion on investigations and treatment plan.

Good luck and keep practicing.

 

CCE.

MBBS Finals 2022 - The End is Near

It is Nov 22, a few more weeks to your MBBS finals. You have already amassed a vast amount of knowledge and hopefully, clinical experience, in the past 10 months or so since your Year 5 program started and soon, all those will be put to the test.

It is even more important now to consolidate your learnings and begin to filter those extra knowledge from those essential knowledge. Take note that not everything you have learned in your daily clinical exposure will be tested in the finals. Understandably so because the spectrum of coverage for everything in medicine is so broad and there is only so much time allocated for each student during the examinations.

This is the time when the study list handed out by your faculty at the start of Year 5 will be most valuable. Use that as a guide for your revision. Narrow down your focus to make revision more effective. Time is of the essence. You wont have time to digest and absorb the entire Harrison’s or Guyton’s medical textbooks.

And with all that knowledge on hand (in brain, actually), it is also equally important to know how to apply those on the exam day itself when faced with the patient in the examination room.

For those who are easily anxious, it would be good to learn relaxation techniques to keep your mind clear. Drawing a comparison with our recently concluded GE15 on Nov 19, 2022 which resulted in a hung parliament, you wont want to have a hung mind during the exam day. Keep your nervousness in check, stay focused with a clear mind, speak the right things (and not everything you see), and god willing (regardless whether you are religious or an atheist, you need some amount of divine blessing during the finals) you will clear the finals and graduate.

Over the next few weeks prior to the final exam date, I will find time to post summaries of approaches to the short case examinations for the major medical station systems and hopefully some spot diagnoses cases.

Do read on and make this blog your revision companion.

All the best.

 

CCE.

Tendon Xanthomas

Dear students,

Sharing with you a case I encountered in the cardiology ward some years ago. It was a case of a young patient in her 20s. She suffered an extensive myocardial infarction few months before I met her in the cardiology ward. She was admitted for coronary angioplasty plus stenting.

She had several siblings who were all myocardial infarction survivors and if I recall correctly, her parents were also cardiovascular patients. She has familial hyperlipidemia. 

I recalled her blood lipid levels were shockingly high and blood samples were very lipemic (oily). She was already on several high dose statins and fibrates. My colleagues in the cardiology team were even discussing plans for a lipid dialysis as they were desperately trying to solve her resistantly high blood lipid levels. The challenge was that the treatment was very limited and only very few centres were offering such treatment options, not to mention the high cost of such treatment as well. 

Below are pictures of tendon xanthomas found on the patient.

For those who have yet to see tendon xanthomas, the above photos depict how one looks like. Good luck.

CCE.

Parkinsonism

Parkinsonism is when there is a triad of bradykinesia, resting tremors and rigidity. There are many causes of parkinsonism. The most commonly seen parkinsonism in the  undergraduate medical final examinations would be Idiopathic Parkinson's disease. 

However, not everyone presenting with Parkinsonism signs have Idiopathic Parkinson's Disease. Therefore students should be wary and mindful about offering the diagnosis of Idiopathic Parkinson's disease upon encountering patients with the above triad. Remember, Idiopathic Parkinson's is a clinical diagnosis and its aetiology is idiopathic i.e. cause is uncertain. Although it is a clinical diagnosis and lab and radiological workup is not required to make the diagnosis, it is also important to consider other differentials causing Parkinsonism signs especially if the patient has risk factors. 

One key feature of Idiopathic Parkinson's Disease is that it is asymmetrical. In the early stages of the disease, parkinsonism can be seen affecting one side of the body. As shown in the video above, this patient has resting tremors affecting his right hand. 

The video below shows bradykinesia affecting the right hand of the same patient. 

As the disease progresses over the years, it may affect the contralateral side of the body as well. However, the key feature remains and Parkinsonism signs would still be asymmetrical. As shown in the next video below, this elderly gentleman has advanced Idiopathic Parkinson's disease as well but take note that the frequency of tremors affecting one arm is different from the other arm. 

Anything that causes damage to the basal ganglia can result in Parkinsonism. For example stroke (vascular), demyelinating diseases, brain tumors, drugs or even metabolic disorders like Wilson's disease. It is good to revise about Parkinsonism as it is a common appearance for the medical examinations. 

CCE. 

 

Chronic Tophaceous Gout

This would be a short case discussion. 

This case is a male patient with multiple joint swellings affecting both upper limbs. The swellings seem to affect the DIPJ, MCPJ as well as wrists. What is also strikingly noticeable is the presence of multiple tophi over the joint swellings. It is not difficult to reach a conclusion of tophaceous gout. 

Tophi are usually found occuring over distal joints or tissues where temperatures are relatively "cooler". This will enable cystallization to occur. This tophi are usually found over distal finger or toe joints, ear pinna. In severe cases, tophi can even be found ocurring almost anywhere on the body as depicted above. 

The next step would be to look for the possible aetiology. Look for psoriatic rashes, polycythemia, hepatosplenomegaly and lymphadenopathies to suggest hematological malignancies.

Then, last but not least, look for complications of the disease itself. Look for sallow coloured skin, dialysis catheters, arteriovenous fistulas to suggest chronic kidney or end stage kidney disease either as a result of obstructive uropathy or chronic NSAID intake for gouty pains. Examine the abdomen for enlarged ballotable kidneys to suggest obstructive uropathy due to urolithiasis. Also look for complications of chronic steroid therapy e.g. Cushing syndrome, hypertension, hyperglycemia (many GP clinics prescribe steroids and NSAIDs to control gouty arthritic pains). 

Remember to apply the triad of diagnosis - aetiology - complications for any case you encounter regardless of short or long case examination. This guide will serve you well and assist you in approaching any case as complete as possible. 

The image above shows central obesity with striation over the anterior abdomen suggesting a Cushingoid appearance. Take note also that there are multiple hyperpigmented scars over the peri-umbilical region suggesting repeated injections likely insulin therapy thus suggesting this patient may have concomitant diabetes mellitus. This will further strengthen the suspicion of Cushing's syndrome. Also notice that there are multiple tophi over the anterior abdominal wall as well. 

Therefore it can be concluded that this patient has been suffering from chronic tophaceous gout for which he has been treated with chronic steroid therapy resulting in secondary Cushing's syndrome. 

Should this case appear for the examinations, the case can be approached from the aspect of gout or can be approached from the aspect of Cushing's syndrome from which the diagnosis of gout is expected to be offered as the underlying main problem. So students should be ready for any possibilities. 

For the long case examination involving a patient with gout, it would be sensible to approach gout from this perspective: 

Gout is due to hyperuricemia.

Hyperuricemia can accumulate due to increased production or decreased clearance. 

For increased production, ask about dietary purine intake, ask about lifestyle (alcohol), ask about cell hemolysis (can be from polycythemia, can be from large solid tumours, can be from hemolytic anemia), ask about tissue damage (burns, surgery, trauma) and last but not least genetic factors (so ask about family history). 

For decreased clearance, ask about dehydration, ask about medications e.g. ACE inhibitors or ARBs or diuretics or aspirin which impedes uric acid excretion and ask about underlying kidney diseases.

Lastly remember to apply the triad of diagnosis - aetiology - complications as well to make your history complete. 

CCE.

Tackling A Case Of Stroke For The Long Case Examination

As an undergraduate, you are highly likely to encounter a case of stroke in the medical examinations either in the long case format or short case format.

Making a diagnosis of stroke is not difficult.

So, how do you suspect a patient has had a stroke?

From history taking, the patient may provide information regarding weakness affecting one side of the body i.e a hemiparesis or a single limb i.e. a monoparesis. The patient may also have cranial nerve involvement, presenting with diplopia, ptosis, facial asymmetry or slurred speech. It is uncommon to get a patient with dysphasia or aphasia for the undergraduate exams as this will impede history taking and physical examination. Nevertheless, you may still encounter a patient with aphasia or dysphasia if there is a shortage of neurological cases for the exams.

The student will be expected to take necessary detailed history pertaining to the right sided hemiparesis e.g. onset of weakness, progression of weakness, and severity. From history taking it is difficult to determine if the patient has had an ischemic stroke or a hemorrhagic stroke. However, in general, if the patient complained of a sudden severe headache preceding or occurring concurrently with the hemiparesis, it is always good to exclude hemorrhagic stroke first. In real life practice, there are many cases of hemorrhagic stroke where the patient presents with just sudden onset of limb weakness without any headaches. The severity of the hemiparesis is not a good indicator to suggest an ischemic event or a hemorrhagic event. There are cases of basal ganglia hypertensive hemorrhages where the patient only has a mild hemiparesis of 3-4/5 whereas there are cases of left middle cerebral artery territory infarctions with dense hemiparesis of 0-1/5.

Once you have decided that the patient has a hemiparesis, you can make a diagnosis of a stroke. If the student has already decided that this presenting complaint is likely due to an ischemic stroke, then a reasonable differential diagnosis would be hemorrhagic stroke. It is also applicable vice versa i.e. if the provisional diagnosis is a hemorrhagic stroke, then the differential would be an ischemic stroke. Only a CT brain can confirm the diagnoses.

Remember to explore other possible differentials as well. Ask about prolonged headaches, constitutional symptoms to suggest a brain tumour. Ask about stepwise deterioration of neurology e.g. history of facial asymmetry 10 years ago, then history of numbness affecting left leg 7 years ago, then history of bladder incontinence 3 years ago etc. This may suggest a possibility of a demyelinating condition such as multiple sclerosis. Also ask about recent head injury or trauma which may suggest a intracranial hemorrhage causing the stroke like symptoms. And also ask about fever, rashes, photophobia, neck stiffness or altered behaviour to suggest intracranial infection e.g. meningitis or cerebral abscess.

Once the student has established the diagnosis and its differentials, the next step should be to explore the aetiology. From history, ask about risk factors for the stroke i.e. hypertension and its BP control, diabetes and its glycemic control, dyslipidemia and its lipid control, history of ischemic heart disease, history of cigarette smoking or chronic alcohol consumption/ abuse, connective tissue disorders (especially if the patient is young, explore regarding anti phospholipid syndrome), medication history (compliance to medications as well as whether patient is on anti-platelet therapy or anti-coagulation therapy) and history of head injury. It is also good to get a detailed family history regarding cardiovascular risk factors as conditions like diabetes, dyslipidemia, hypertension may run in families. Also explore regarding dietary habits – fast food, oily food, high salt diet, lots of processed foods etc. These aetiologies are supporting a diagnosis of ischemic/ hemorrhagic stroke. Remember to get history regarding aetiologies for the other differentials too if relevant to your patient. 

Next step would be to explore complications that may arise from the stroke. Ask about headaches, blurred vision which could indicate raised intracranial pressure. Also ask about fever, cough, dyspnoea and choking episode to suggest that the patient may have aspirated. Ask about seizures as post stroke patients have tendency for seizures. Ask about falls and physical injuries due to the physical limitations as a result of the stroke. Ask about cognitive impairment or change in consciousness (very unlikely to get a demented or delirious or confused patient in the exam setting!).

Last but not least, explore about the patients social history in more detail than usual. As stroke affects the patient’s life very significantly, it is also good to know the patient’s baseline functionality e.g. right or left handedness, occupation, breadwinner or not, living at home with whom, hobbies, staying in what sort of house (single storey versus multi storey and whether there is lift facility). All this will give a rough idea on how the stroke may impact the patient’s life once he is discharged from the hospital. The information obtained will help you plan for long term management. For example if the patient is the sole breadwinner of his family and he is no longer able to work, then you may offer referral to social welfare for assistance. Another example would be if the patient is right hand dominant and is a typist and loves to play tennis using his right hand and he just suffered a stroke with right hemiparesis, then he will benefit from occupation therapist referral to get him to adapt and learn to adjust using his left hand while awaiting right hand to recover with rehab (if at all possible). 

Once the above mentioned has been settled, the student should go on to complete the other components of history taking to ensure a complete history is taken e.g. drug history, allergy history, surgical history, etc.

For physical examination (from head to toe), 

Head:

Examine the Glasgow Coma Scale (GCS) and also orientation to time, place, person. Look for cranial neuropathy if it is suggestive from the history taking. Example, if the patient complained of facial asymmetry and slurred speech, then it is probably worth examining the facial nerve and the cranial nerves 9,10,12 properly. If upon general inspection there is eye deviation or ptosis, then a proper examination of the cranial nerves 3,4 and 6 is warranted. Otherwise it is unnecessary to do a FULL cranial nerve examination. Time is the limiting factor here! If the student managed to complete history taking within a short time frame, then perhaps when there is ample time, the student may still do a concise but full cranial nerve examination (The olfactory nerve is probably the least examined cranial nerve as it rarely appears for exams. So be smart when choosing which cranial nerve to examine). Look for risk factors for stroke: xanthelasma, arcus senilis, acanthosis nigricans (darkening and velvety like skin over the neck and flexure area). Also assess speech and nystagmus if history suggests cerebellar involvement. 

UL:

Finger prick marks for diabetes mellitus. Nicotine stain over the finger nails. Tendon xanthomas. Upper motor neuron (UMN) signs affecting the weak arm: hypertonia, hyperreflexia. And also quantify the weakness using the MRC scale 0-5. Also check sensory deficits. Remember to check cerebellar signs as well if not yet done as part of the CN assessment. Important to check the blood pressure using sphygmomanometer as well. 

LL: 

Check for UMN signs affecting the weak leg: hypertonia, hyperreflexia, clonus, upgoing Babinski response. Quantify the weakness using MRC scale. And check for sensory deficits. Cerebellar assessment is also important if not yet done for UL or CN assessment. However if while assessing CN and UL and no cerebellar signs were detected, then it is not necessary to do cerebellar assessment for LL. Last but not least, ask the patient to walk to assess gait (do this only if the patient is able to walk. Do not cause a fall which may injure the patient). 

CCE.

Diabetes Mellitus - How to Approach a Patient with Diabetes Mellitus in the Long Case Examination (Physical Examination)

Once you have completed the history taking, you will know which system to examine more thoroughly i.e. the system that correlates with the primary or chief complaint. For example, if the chief complaint was numbness in the feet, then a thorough examination of the lower limbs would be the next logical step. 

For the purpose of this blog, I'll list out the things required for examination in general. You may tailor the examination requirement based on the patient you've clerked in the exam. 

General Examination:

1. GCS - always good to assess this. An alternative is the orientation to time/ place/ person assessment. The patient's mental state is an important first assessment for a diabetic patient as such patients are prone to cerebral ischemia, neuroglycopenia, hyperglycemic complications e.g. HHS and even vascular-related neurocognitive impairments. 

2. If the patient has trouble remembering many facts during history taking, you may want to offer to do a Mini Mental State Examination (MMSE) at the end of the presentation to identify presence of and severity of cognitive impairment or dementia at the end of the patient's examination (however, this will not be possible in the real exam setting due to time constraints). 

3. General appearance - Acromegaly, Cushingoid, thyrotoxicosis as these conditions may predispose to development of DM or aggravate DM control. Also look out for skin changes e.g. pallor or sallow coloured skin to suggest presence of chronic kidney disease and rashes that may suggest presence of connective tissue disorders e.g. systemic lupus, psoriasis, systemic sclerosis etc. Do take note of the peripheral joints as well especially the fingers, toes and ankle regions for any deformities to suggest a chronic inflammatory arthropathy or gout. The earlier mentioned conditions may all be treated with steroids for a prolonged period of time resulting in hyperglycemia or steroid induced diabetes mellitus.

4. Accessories - intravenous drips, insulin syringe pumps, intravenous antibiotics, oxygen support, orthoses (ankle splints for foot drop or limb prosthesis), customised shoes for Charcot foot or walking aids. Also improtant to take note of presence of arteriovenous fistulas and dialysis catheters (internal jugular or femoral dialysisc atheters)

5. Eyes - at least a visual acuity assessment using a portable modified Snellen's chart and RAPD assessment for any retinal or optic disc abnormality. If there is RAPD detected, then the next assessment would be funduscopy for diabetic retinopathy if time permits.

6. CVS - look for displaced apex with murmurs, raised JVP and bibasal crepitations to indicate heart failure (coronary artery disase is a complication of long standing and uncontrolled DM)

7. Respi - examination of this system should be selective. Look briefly for evidence of fluid overload e.g. basal crepitations to suggest pulmonary oedema or stony dullness percussion note with reduced vocal resonance to suggest pleural effusion. 

8. Peripheral pulses especially the distal pulses e.g. dorsalis pedis,/ posterior tibialis pulses. This would be more relevant if the patient reports claudication pain during history taking. Auscultation of the carotid arteries for any bruit to indicate stenosis is also important if time permits. Do take note that uncontrolled diabetes mellitus may accelerate atherosclerosis changes along major arteries. 

9. Neurological examination - particularly the lower limbs. You may limit the neurological examination to information obtained during history taking. For example if the patient reports that he has history of right sided leg weakness, then perhaps it is sufficient to focus your neurological examination to the lower limbs only, while briefly screen through neurological examination of the upper limbs and cranial nerves. Conducting a full neurological examination as a routine assessment during long case examination can be challenging due to time constraints. The earliest sign of diabetic peripheral neuropathy is loss of vibration sense and loss of proprioception in the distal joints e.g. interphalangeal joints in the toes. Also look out for diabetic foot ulcers, calluses over bony prominences and trophic changes affecting the skin over the lower limbs which may strongly suggest presence of peripheral neuropathy. 

10. Abdominal examination - look for signs of lipohypertrophy or lipoatrophy to suggest repeated insulin injections. This can usually be found at the periumbilical region. If found, it would be important to highlight this finding during the case presentation as it will impact treatment outcome. Patients that fail to rotate the insulin injection sites adequately will have the above changes occurring and this will impair optimal insulin absorption and affect adequacy of glucose control. Look for Tenchoff catheters over the anterior abdominal wall to suggest patient has ESRF and is undergoing CAPD. Also look renal transplantation scars to suggest a history of diabetic kidney disease (renal transplant scars are usually J shaped and located at either right iliac fossa or left iliac fossa regions). It is also possible that immunosuppressive therapy post organ transplant be the aetiology for diabetes mellitus in such a patient. Do consider palpating the abdomen for an abdominal aortic aneurysm as well. 

11. Lastly, do steal some time to screen the patient's body for any cutaneous infections like carbuncles, furuncles. Look also for tinea infections affecting the skin flexures e.g. axillary, infra-mammary, groin area. In uncontrolled diabetics, skin infections may be extensive. 

CCE