LONG CASE (MEDICINE)

Prof Hamidun, Prof Hashim, Prof Ismail & Dr (external)

<Same case with Afiq Adli>
Her HOPI was quite a long and confused one, but here are some of the details:Madam K, 49 year-old single Malay clerk with underlying controlled HPT and
autoimmune disease (seriously I thought that she has only ONE disease but turned
out to be MIXED CTDs) came today for exam purpose. Currently she has no active
complaint.
She presented with non-specific symptoms of SLE; had inflammatory low back pain
15 years ago for about a year then resolved. Then she had intermittent fever +
bilateral (symmetrical) joint pain and swelling involving MCPs, DIPs, PIPs of both
hands and shoulders without any history of morning stiffness, warmness, redness,
deformity or loss of f(x) + myalgia of all muscles + proximal myopathy described as
difficulty of getting up from squatting position + patchy alopecia.
She had no specific symptoms suggestive of SLE (need to exclude based on 4 out of
11 criteria of SLE)
A R A S H P O I N M D ---- really need to memorize these ok! :)
Systemic review was insignificant. There was no history suggestive of other
autoimmune diseases (need to know other autoimmune diseases; meaning to say,
scleroderma, RA, DM, hypo/hyperthyroid, vitiligo, hypoK+ periodic paralysis,
Addisons disease, autoimmune hepatitis, AIHA, AS, dermato/polymyositis, etc).
No family history of autoimmune diseases.
Shes on immunosuppressive therapy (dont forget to ask patient to show her
medications).
Then, we continued with physical examination. Although she had no complaints
suggestive of scleroderma but yes, she has features of scleroderma.
PROFESSIONAL EXAM 2013 6TH BATCH DAY 2
CLINICAL EXAMS
Q&A
1. What are other symptoms that youve excluded in this patient?
Need to know the diagnostic features for SLE & other autoimmune diseases.
2. What are your positive findings?
They asked me to show my significant findings:Multiple skin hypopigmentation of various sizes all over the limbs and forehead (did
not think that they were vitiligo)

Patchy alopecia
Skin tightening
Beaked shape nose
Microstomia
Diffuse redness over both dorsums and palms (Raynauds syndrome)
Otherwise, there were no other abnormalities on hands examination
(exclude features of SLE + scleroderma & ALL other autoimmune diseases which
have significant hands findings).
No other significant findings upon systemic examination (need to exclude FEATURES
& COMPLICATIONS of autoimmune diseases). There were no features of steroid
toxicity.
3. What is Raynauds syndrome?
4. Do you think that this patient looks young?
5. What are the features of steroid toxicity?
6. So what are your provisional diagnoses?
7. Ok, let say patient has SLE + scleroderma, what do call that?
Then, continued with Q&A in the discussion room:8. What are your investigations?
Need to answer based on A R A S H P O I N M D & scleroderma features
FBC looking for macrocytic anemia, thrombocytopenia, leucopenia & neutropenia
PROFESSIONAL EXAM 2013 6TH BATCH DAY 2
CLINICAL EXAMS
Antibodies (ANA, anti dsDNA, anti SMA, anti centromere Ab, anti phospholipid, etc)
LFT and USG (liver cirrhosis in scleroderma)
RP (renal crisis in scleroderma)
Urinalysis for proteinuria & microscopic casts (RBC, granular, mixed)
ECG- low voltage, heart block (scleroderma)
Echo- floating heart
CXR for pleural effusion
OGDS for esophageal dysmotility/reflux esohagitis/esophageal ulcers

You guys can add any other investigations that you can think of. :) But frankly
speaking, I only answered the investigations
for SLE.
9. Why is there macrocytic anemia?
10. Why reticulocytes cause high MCV?
11. If you suspect hemolysis, what other tests that you would like to do?
12. Shes having thrombocytopenia, do you surprised by that?
13. What is the mechanism of thrombocytopenia?
14. How do you manage this patient?
15. Why is she on immunosuppressive drugs?
16. What is the type of Prednisolone that can be given as long term management?
Ans: Methylprednisolone (blurrrr time ni, huhu)
17. If she is young and she is pregnant, how do you manage her? (this was asked by
Prof Hashim)
As I opened my mouth trying to answer, ting ting ting, TIMES UP! Huhu
CONCLUSION: This was a case of mixed CTD (SLE & scleroderma), Im not whether
she has RA or nor since arthritis in SLE pts is also rheumatoid-like.

3. Izwan Ariff (19-->17) Long : MED (Dato Amin, Dr azizah, Dr Norneza n external
surgeon) Nalili, 48yrs old Indian f, w RA, Type 2 DM, Hypothyroidism Q: How to diff
RA,OA,Gout n Psoriatic Arthropathy ? How to diagnosed RA. G jmpa ptnt- dia suruh
describe the hand.. pastu do general examination pertaining to DM. Then, ptnt tu
mcm ada varicose vein sket.. Surgeon tu tnya define varicose vein.. describe the
usual site of VV. How many % does normal individu in our population has +ve RF? If
ptnt has bilateral muscle wasting w joint pain.. wat do u think the dx? What is mixed
connective tissue dz? Invx n management for this patient (including DM n
hypothyroid)

1. Dalila lala Examiner: Lead EXT medical, pead; Dr Wan Jazilah, O&G; Prof Hashim,
surg: Ext from Selayang Hospital LONG CASE Pn. Roslinda a 44 years old separated
Malay lady, with underlying mixed connective tiss. disease of SLE, polymyositis and
scleroderma associated with Sjogrens Syndrome for 10 years complicated with lung
fibrosis, came in today for examination purpose with no current active complaints.
(this was edited, not the exact opening statement that I presented) Initially having
photosensitivity, whole body rashes, alopecia, arthritis, felling fatigue, proximal
muscle weakness, tightening of skin esp at the face and hands, dysphagia,
dyspepsia, Raynauds phenomenon during cold environment and stress, SOB on

exertion, dry cough, orthopnea, PND, occasional chest discomfort all started since
2003 but only sought medical attention a year later for SOCSO application. No
psychosis, no renal symptoms. Medication: prednisolone, was on AZA (stopped dt
pancytopenia), pantoprazole, neurobion, ferrous sulphate, fucidin cream, hydrocort
cream, MDI salbutamol, MDI ICS+LAAC, montelukast. Allergy to cefuroxime. (patient
showed her prescriptions slip) Multiple admissions due to these symptoms, with the
latest on 2007 due to low Hb picked from routine follow-up in Hospital Selayang.
Investigations done was ANA+, schimers test +, muscle biopsy, HRCT (lung
fibrosis), echo. (these info was extracted from her medical records as she brought
them along. Social: separated from husband who is currently locked up in prison for
drug abuse and is HIV +. Currently living with 12 year old daughter in rented long
house from DBKL in Jinjang. Works as a security guard in a primary school with basic
income of ~RM 900. Supported by zakat, SOCSO, and overall income per month
~RM 1000. (Had a hectic & hard time clerking her and didnt managed to get a
proper timeline. Most questions was close ended, and had to juggle between
clerking and looking at her copies of medical records. Not sure whether it was a
correct way or otherwise. My mistake was focusing too much on her notes and was
blinded by them as it was with the dx of polymyositis & scleroderma &
keratoconjuctiva
PROFESSIONAL EXAM 2013 6TH BATCH DAY 4
CLINICAL EXAMS
sicca to the point of missing SLE (not stated or x terbaca dlm notes die) in the
opening statement and summary even though most of her symptoms were of SLE)
PE: (only started at the last 20 mins) -Gen: tight skin, beaked faced, small mouth
(still able to put in 3 fingers), hands sclerodactyly) -lungs: good air entry bilaterally
with fine inspiratory creps in bilateral lower zone. -MSK: proximal UL 5/5, proximal
LL 3/5 (cant get up from squatting *** make sure to place the hand crossed touching
the shoulder cam nk ketuk ketampi when asking pt to get up from squatting)
DISCUSSION: Q: did the pt mentioned to u her diagnosis and polymyositis &
sclerodema? A: yes and she also showed her medical record Q:How do u diagnose
SLE A: 4/11 criteria (managed to answer the first 5 then dr stopped me) Q: how to u
investigate? A: based on the criteria. Blood investigation: FBC, RP, C3/C4, ESR,
serology anti-dsDNA, ANA Q: what are the symptoms of polymyositis A: MYALGIA,
muscle weakness, respiratory muscle weakness, dysphagia Q: what is the
pathophysiology of thrombocytopenia in SLE A: Antibody-mediated destruction of
peripheral blood cells may cause neutropenia, lymphopenia, thrombocytopenia or
haemolytic anaemia (Davidson) Q:why SLE pt develop anemia? A: 1. AIHA 2. IDA
secondary to GIT dt oral steroids 3. Anemia of chronic dz Q: what is the autoantibodies for polymyositis A: antisynthetase (e.g. Jo1) antibodies (Davidson) Q:
how to do tx SLE A: mainstay RX is prednisolone, steroid sparing agent; AZA,
Hydroxychloroquine methotrexate, ciclosporin, tacrolimus, mycophenolate mofetil)
ON PE: Q: what is the type of alopecia occurred in SLE? A: diffused non-scarring in
acute disease, scarring alopecia dt discoid lupus on scalp Q: grade muscle power A:
based on MRC scale of muscle power Q: what is grade 3? A: against gravity but not
against examiner's resistance Q: please ask the pt to squat A: do as mentioned

above (PS these are the qs that is was able to recall, and not all of them were
answered correctly or promptly. I looked up for the answer 1 day after clinical mostly
form davidsons. Selawat byk, tawakal pada Allah, hanya Dia sebaik2 penentu masa
depan kita. Selawat and zikir utk tenangkn diri. InsyaAllah dipermudahkan
perjalanan kita)

LONG CASE : Medicine - Rheumatoidarthritis with Myasthenia Gravis

Examiner : Dominant (Dr Fatimah, Dr Razali), Prof Syed Hassan, Prof Suneet, Dr
Param

Summary:Madam Soh, 44 year oldChinese lady, housewife from Kepong, ADL

independant, with background historyof RA dx since 2 years ago on T. arava and
MTX with prev hx of Myasthenia Gravis dx 15 years ago, thymomectomy done
currently complaining of swelling of left elbow, left knee and right ankle, not in flare
i.e no pain, stiffness, joint redness or fever with strong family history of SLE (2 of her
siblings and her eldest daughter).

(Actually joint pain started since 10 years ago, initially treated as SLE, treated with
prednisolone for 10 years develop Cushingoid fx, tp dx ditukar ke RA since 2 years
ago)

o/e (positive findings)

Hand - Boutonierre's deformity of middle finger of R/L hand, 1st MCP swelling, no
joint redness/tenderness. Fine and gross motor movement of hand intact.
Wrist - limited flexion/extension
Elbow - bogginess noted at L elbow, no tenderness, full ROMKnee - L knee swelling,
limited ROM, unable to squat
Ankle - R ankle swelling, limited ROM
Shoulder, Hip, Spine NAD
No rheumatoid nodules
Systemic - NAD, no other extraarticular features

After present history, pegi kat pt buat PE and real Q&A started.

1. how do you check for muscle wasting of thenar/hypothenar - ku buat mcm yg mr

faisal ajar masa kelas ortho tu
2. what type of lung fibrosis RA have - lower lobe
3. what is the ddx for pt unable to squat? - dr nak dgr proximal myopathy secondary
to steroid.
4. show me how to check for proximal myopathy
5. let say pt came to casualty with such presentation, how do you investigate
6. what is the pathophysiology of RA - immunologically mediated rxn causing
sinovitis, later joint destruction
7. pls explain how the joint swelling develop - dia nak dgr synovial thickening
8. tell me the genetic behind RA - erk. HLA DR23, HLA DR4
9. what is mixed CT disease?
10. what is the side effects of
MTX?
11. what other medication can we give to patient besides what was given
immunomodulator
12. what is the criteria for SLE that patient not fulfill prior to this?

Ada bbrp lagi tp xingat, n before abes Prof Suneet mencelah.

13. what is collagen?
14. tell me types of protein, fats

Ibrah:
1. Yakinlah bahawa case yg korg dpt tu mmg case terbaik utk korg, sungguh! Aku
initially down sgt ble dpt tau dpt RA, aaaaa why why? tp Allah tu Maha Mengetahui.

2. Focus kat social/function especially patient cmni, dr tny jugak mcmana pt BO,
tandas cangkung ke duduk sbb pt ni takleh squat.

3. N be confident despite hx lacking/patchy, insyaAllah they will buy your

confidence