Acute Glaucoma

Acute Angle-Closure Glaucoma occurs when the drainage of aqueous humor via the anterior chamber angle is blocked by the iris. People with shallow anterior chamber, either due to short axial length in hyperopia, or enlarged lens by development of cataract. Patients often complain of blurry vision and painful eye, with headache, nausea and vomiting.

Classical clinical features:

• mid-dilated pupil
• "deep-sea-green" pupil
• corneal oedema & injection
• circumcorneal redness
• abrupt rise of intraocular pressure

Acute glaucoma is treated as emergency. Medical treatment includes acetazolamide, beta blockers, pilocarpine, prostaglandin analogue, and alpha-2 adrenergic agonists. If medical treatment failed, laser iridectomy or surgical intervention is needed.

A restless patient

You were called to the surgical ward to see a restless patient. The patient was 50 years old and he underwent an appendectomy 2 days ago.

On examination, the patient was very restless, agitated and confused. There was tremor of the hand. His heart rate was 110 bpm, blood pressure was 150/90 mmHg. Heart & lung sound was normal. Neurological examination was normal.

His had no significant past medical history. He did not smoke, but drank 2-3 cups of wine everyday.

1. What is your clinical diagnosis?

2. Name the condition when an alcoholic patients with chronic thiamine deficiency develop CNS manisfestation.

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Post-op Hypotension

A 65-year-old woman has undergone a surgery due to fracture of right head of femur 2 days ago. The surgery was successful and she was admitted in the ward. Since then, she started to develop hypotension. She also complained of nausea and vomiting.

From her past medical history, she underwent total hysterectomy with bilateral salpingo-oophorectomy 20 years ago, due to dysfunctional uterine bleeding. She also had arthritis and was taking chinese herb given by a chinese "sin-seh".

On examination, her blood pressure was 80/50 mmHg and she was tachycardic. She was obese and there were signs of skin atrophy, together with some purpura on her skin. Otherwise, she was normal. ECG showed sinus tachycardia.

From the medical report, she was well before operation. Blood test result before operation were normal, except that Pottasium level is 3.5 mmol/l (borderline low); Hb is 16g/dL (higher end). The blood pressure before surgery is 100/70mmHg. The surgeon reported that there were not much bleeding during the surgery, and the patient's Hb after surgery was 14g/dL. Anaesthesiologist ruled out side effects of GA.

1. What is the most likely cause of the fracture? Name 2 risk factors of this woman that lead to the condition.

2. What is the your clinical diagnosis of hypotension in this patient?

(Clue: chinese herb, surgery, clinical features, history)

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Woman with Abdominal Pain

Here comes my very first case.

Hx:

A young woman, 30, was brought to the hospital by her husband. She complained of abdominal pain few hours ago and was fainted on the way to hospital. Her LMP (last menstrual period) was 30 days ago and she noticed some spotting few days ago. Otherwise, the history was normal.

On examination, the woman was pale. She was hypotensive and the heart rate is tachycardic. She appeared to be in shock. Abdominal palpation show mild generalised tenderness, no guarding, no rebound tenderness.

1.What is the first diagnosis to rule out? (Clue: emergency)

2.What investigation will you carry out to confirm your diagnosis?

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