Short cases

Background/ Findings Differential

question diagnosis

Cardiovascular System

1 13 years old Inspection: 1.VSD

malay boy. A.​ ​Stage 1 clubbing Pacemaker due to
Please do B. Tachycardia previous right heart
cardiovascula C. Central cyanosis? failure?
r examination. D. Obvious pulsation over the 6th left
intercostal space anterior axillary line 2.Cyanotic heart
E. Midline sternotomy scar disease
F. Scar over the scapula region at the
back(posterolateral thoracotomy)
G. Pacemaker implant at left upper chest
midclavicular line(pacemaker scar)
H. Hyperinflated chest
Palpation:
I.​ ​Apex beat displaced to left 6th intercostal
space anterior axillary line
J. No palpable heave or thrill?
Auscultation:
K. Pansystolic murmur best heard over left
lower sternal border,grade 3/6 OR grade
4/6

2. 9 years old Inspection : 1.VSD

Down A. Peripheries: finger clubbing, weak pulse.
Syndrome peripheral cyanosis 2. AVSD
Chinese Boy. B. Mouth: central cyanosis
Pls perform a C. Praecordium : surgical scars? Pectus 3. Cyanotic due to
CVS carinatum?? Eisenmenger
examination. Palpation : syndrome?
D. Apex beat: not displaced
Auscultation :
E. systolic murmur best heard at Left lower
sternal border, no thrills (Grade 3)

*No hepatomegaly, No signs of heart failure

3. 13 years old Inspection: 1. Marfan

Malay girl, A. General : Legs flexed on the bed(too long syndrome with
Please to fit bed) cardiovascular
examine the B. Peripheral: fingers are long and complication(mitral
hands and slender(arachnodactyly), curved, long valve prolapse)
 praecordium. and thin forearms and arms, Positive
Steinberg sign and positive Walker
Murdoch sign, flexible joints,
C. Oral: Crowding of teeth.
D. Precordium: Obvious chest
deformity(pectus carinatum), No surgical
scars, No visible pulsations
Palpation:
E. Apex beat left 5th ICS,MCL
F. Thrill felt at lower left sternal border
Auscultation:
F. Systolic murmur(Grade 4) best heard at
left lower sternal border.

*I would like to complete examination by

measuring the arm-span-to-height ratio(>1.05)
and upper segment/lower segment ratio(Head to
SP/ SP to sole < 0.85)

Neurological System

4. 14 year old Inspection : 1. Lower motor

Indian female A. Wheel chair neurone lesion
Pls perform a B. Scar on left dorsum of foot
lower limb C. See abnormal involuntary movement on 2. Duchenne
examination left foot. Muscular Dystrophy
No fasciculation
Tone : 3. Spina Bifida
D. Hypertonia, sometime hypotonia ==#
Power:
E. Bilateral lower limb muscles weakness.
F. Power cannot be tested
Reflexes:
G. Hyper reflexive
Barbinski sign:
H.​ ​Down going
Clonus​ :
I. No

*Sensory, coordination, heel shin test and gait

cannot be assessed.

5 Patient X Inspection: 1.UMNL

female 13 A. General: Comfortable, pink, no
years old​. respiratory distress 2. Cerebral plasy
Examination B. Face : Dysmorphic feature spastic type with
 neurological C. Head : Small head circumference ( ideally diplegia
status of would like to further access with tomographic
lower limb growth chart and measure head distribution (but
circumference) appropriate ideally need to
nutritional status access UL to
D.Lower Limb : No fasciculation, scar noted COMFIRM)
on Left LL dorsal region,
muscle wasting of bilaterally 3. Spina bifida
******( Prof M: specify the muscle group lost : calf
muscle lost & reason: disuse muscle atrophy) , no
bone deformities but noted equinovarus of left leg
Tone:
E. Hypertonia both lower limb but more prominent
left side with spasticity of ankle joint ,
Power :
not applicable because patient is mentally
challenge
Reflex :
F. Hyperreflexia of both lower limb grade 3 plus
but more noticeable left sided,
Barbinski:
G. Downgoing
Clonus:
H. no ankle clonus

*Sensation, proprioception and coordination not

applicable because patient mentally challenge

Discussion:

- Investigation : MRI brain & EEG

- Management : Muscle relaxant( example :
baclofen)

6. 1 year 7 Inspection: 1.UMNL

months old A. General : Lying on bed, appear to be
Indian boy. irritable.appeared thin to age, 2. Spastic
Do a general abnormal posturing with both quadripelgia
inspection arm flexing, back arching, cerebral palsy
and extension of both leg secondary to ?
neurological (opisthotonus). head trauma
examination B. Head : Appeared to be deformed with 2 (shaken baby
surgical scars over both parietal syndrome) @
region. intracranial
C. Nose : NG tube over right nostril, hemorrhage
D. Peripheries: Branula over right hand, , no
 joint deformity and no
muscle wasting.
E. Eyes: not following hand movement and
light (loss vision?)

Tone:
E. Very hypertonic over four limbs (spasicity?)
(quadripelgia?)
Power:
unable to assess
Reflex:
unable to assess (patient not relax)
Clonus:
unable to assess
Barbinski:
F. left side up-going, right side unable to assess

Discussion:

-​ ​NG tube: oromotor incoordination

- Head deformity: measure HC and plot
growth chart

Abdominal System

7 20 years old Inspection: 1. Thalassemia

Malay girl. Pls A. Peripheries: Scar at cubital fossa major
do abdominal (transfusion scars)
examination. B: Eyes: Scleral jaundice 2. Sickle cell
C. Face: Prominent maxillary bone anemia
Palpation:
D. Abdomen;soft ,non tender 3. Hereditary
E. Hepatomegaly: 3 cm palpable from spherocytosis
subcoastal margin
F. Splenomegaly:2-3 cm palpable, dullness
traube’s space

Discussion:

- Investigation: FBC, Peripheral Blood Film

Hb Electrophoresis(B-thal).
DNA analysis (A-thal)
- Treatment : Blood transfusion
Iron chelating agent
(a) desferrioxamine - s/c
(b) deferiprone - oral
(c) deferasirox - oral
Respiratory System

8 16 years old Inspection: 1. Chronic

Indian boy. A. Peripheral : Finger clubbing, no cyanosis, suppurative lung
Do a appears pink disease
respiratory B. Precordium : Small chest tube drainage
examination. scar noted on the right lateral chest ( 2. Bronchiectasis
around 2cmx 2cm), Bulging of the right
chest (not sure if pectus carinatum) 3. Cystic Fibrosis
Palpation:
C. Chest expansion symmetrical
Percussion:
D. Resonance
Auscultation:
E​. ​breath sounds vesicular, reduced air
entry? no rhonchi, generalised crepitations
bilaterally.

OSCE

1. (video on whooping cough)

This is a 4 months old child presented with prolonged cough for 3 week. The cough is
preceded by coryza.

a. What is the most likely diagnosis

- ​Pertussis/ Whooping cough

b. ​ ive one complication from this condition

G
- Pneumonia
- Bronchiectasis
- Apneoa
- Subconjunctival haemorrhage
- Cerebral abscess ?

c. What medication that can be use to treat this problem

-- Erythromycin syrup/iv?

d. What are the immunisation that the child should have receive to prevent the
disease

Type of vaccine Recommended dose Recommended time

 DTaP (Diptheria, Tetanus 1st dose 2 months old
and Pertussis)
2nd dose 3 months old

3rd dose 5 months old

booster 18 months old

2. A 4 week old baby boy was found to have yellowish discolouration. Please take proper
jaundice history from his father. (focused on her sign and symptoms) ?

a. Summarise your finding in one short sentence/ phrase.

- Obstructive jaundice

b. Give 2 most probable diagnosis from your findings.

- Biliary Atresia
- Choledochal cyst
- TORCHES
- Neonatal hepatitis

Onset​:
Start on the 4th day

Duration​:
Lasted for 4 weeks

HOPI​:
** Yellow discolouration mainly on her face.
1. Pale stool
2. Dark colour urine
3. No vomiting
4. No diarrhoea
5. No fever
6. Follow up history : Seen a doctor and blood test done showed that there was increased
serum bilirubin (200+). Appointment in 1 month time. Defaulted follow up
as there was a relative passed away and the parents were busy.
7. Feeding history : can tolerate feeding well (exclusively breastfeeding : 1-2 hourly per day)
Put on weight 200g in 2 weeks
8. Phototherapy : x done, was put under the sun but did not resolve
9. Blood transfusion : No
10. No irritable
11. No lethargic

Past medical history​ : No

Past surgical history ​: No

Birth History :
Antenatal history:​ This is the first child. Ask about mother’s blood group (can be rhesus
incompatibility causes serious haemolysis, anaemia and severe jaundice)

Intrapartum history​: mother got any infection during the pregnancy

Postpartum history​ : ask for the cord blood result(G6PD, Hypothyroidism)

Family history :
- No history of prolonged jaundice
- No thalassaemia
- No G6PD