An old lady with breathlessness

A 70-year-old lady present to the clinic complained of breathlessness on exertion since a month ago. There was no chest pain but she felt palpitation occasionally. On further questioning, she mentioned that she had to sleep on 2 pillows at night and might wake up suddenly due to shortness of breath. She also felt tired easily and noticed some loss of weight. Her appetite was not good nowadays. She had no significant past medical history and family history. She did not smoke nor take alcohol.

On examination, the patient appeared tired ad there was no sign of cyanosis, pallor or jaundice. Her pulse rate was 110bpm, rhythm was irregularly irregular, volume was strong. Her respiratory rate was normal. Blood pressure was 150/70mmHg. JVP was raised. Body temperature was normal.

Examination of the heart showed that her apex beat was slightly displaced to the lateral. On auscultation, there was a ejection systolic murmur. Auscultation of the lung revealed basal crepitation. Abdominal examination showed slight enlargement of the liver, no splenomegaly, kidney not palpable. Peripheral pulses were all palpable, symmetry and strong. There was mild pedal oedema.

ECG showed irregular rhythm with normal QRS complex. There was no pattern suggestive of previous myocardial infarction. Chest X-ray showed signs of pulmonary oedema and cardiomegaly. Blood test was normal except for elevated serum T3, T4 level.

1. What is the most likely clinical diagnosis?

2. What type of irregular rhythm was expected on ECG?

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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Man with weakness of legs

An Asian male, 30, working as a pilot, came into the clinic and complained of weakness in his legs since 2 days ago. He also complained of tiredness ocassionally. There was no history of back pain or trauma. The history was otherwise normal.

On examination, his heart rate was 110bpm. The skin was warm and he was sweating profusely. His muscle strength and tendon reflex were good. The physical examination was otherwise normal.

Investigation was done and the doctor noted tat his Serum T3, T4 level were high, showing that he had thyrotoxicosis.

1. What is the most likely cause of the weakness in the legs?

(Clue: Asian male, thyrotoxicosis)

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