Grand Ward Round

MMW Team A
17th July 2019
Patient information
• Mr X
• 38 years old gentleman
• Work as security at school
• Married with 1 child
• Smoker (smokes 5 sticks/day x 2 years)
• Alcoholic (start drinking alcohol since 20 years old, can drink up to 14
tins of beer/day)
• Ex-IVDU, stopped 15 years ago
• No known medical illness, no known allergies
History of Presenting Illness
• Presented with diarrhoea x2/7, 3 episodes per day, brownish stool, no
blood in stool
• Followed by rashes started from lower limb, then spread up to
abdomen, non itchy
• Associated with bilateral feet swelling and weakness x 2/52
• Weakness starts from foot, up to thigh
• Has on and off fever x 2/52, associated with chills and rigors
• Bilateral ankle and knee pain x 2/52
• On further history
• Complaint of palpitation and tremor x 3/12
• No history of travelling/swimming in river
• No history of fall/trauma
• No night sweats
• No hematuria
• No history of taking traditional medication/over the counter
medication
Physical Examination
• Alert, conscious, GCS E4V5M6, not tachypneic
• BP: 142/92 PR 118 RR 18 SpO2: 98% under RA, T: 36.4
• Exophthalmos, fine tremor
• No goitre seen, no carotid bruit
• Oral cavity: no oral thrush
• No IV injection marks
• No cervical lymph nodes palpable
• Lungs: clear
• Abdomen: soft, non tender, distended
• Raised, purpuric rashes over bilateral lower limb up to abdomen, non blanchable
• Bilateral lower limb: Pedal edema
 Right Upper Limb Left Upper Limb Right lower limb Left lower limb
Tone Normal Normal Normal Normal
Reflex ++ ++ ++ ++
Sensation Intact Intact Intact Intact
Power 4/5 4/5 3/5 3/5
Babinski Downgoing Downgoing

Cranial nerve examination grossly normal

No cerebellar signs
Blood investigations
29/6 LFT
Hb 17 TB 21
TWC 26.03 DB 6.3
Plt 464 AST 29
ALT 29
29/6 ALP 88
Na 127 Alb 30
K 3.8 Ca 2.07
Cl 95 PO4 0.74
Urea 5
Creat 67
UFEME
pH 6.0
Specific gravity 1.020
Leucocyte Negative
Nitrite Negative
Protein Negative
Blood Negative
Glucose Negative
Urobilinogen Negative
Color Pale yellow
CXR
Impression…
1. Vasculitic rash for investigation
2. Likely hyperthyroidism
3. Alcoholic liver disease with hypoalbuminemia
Further investigations
• ESR: 10
• RF: negative
• ANA: negative
• ANCA: Pending
• TSH <0.005 FT4 24.15 fT3: 3.97

• VDRL: NR
• Hep C: Repeatedly reactive
• Hep B: NR
• HIV: NR

• uPCR: 0.39g/day

• Echo 1/7/19: EF 71%, no RWMA, no thrombus/vegetation, normal LV contractility

Dermato input
Leucocytoclastic vasculitis, likely secondary to infection/Hep C

Skin biopsy was taken on 2/7/19

Started on IV methylprednisolone 500mg OD x 3/7, then T

prednisolone 15mg OD for 2/52

HPE skin: Findings consistent with leucocytoclastic vasculitis

• In ward, developed generalised abdominal pain with rebound
tenderness
• Referred to surgical to rule out ? Vasculitic induced mesenteric
ischemia

• CT abdomen 3/7/19: Long segment small bowel thickening of

jejunum and terminal ileum with mesenteric lymphadenopathy, may
indicate inflammatory changes or infection, less likely ischemia
Final diagnosis
1. Newly diagnosed hyperthyroidism
- Started on T. carbimazole 20mg OD and T. propranolol 40mg BD

2. Newly diagnosed Hepatitis C

3. Leucocytoclastic vasculitis likely secondary to infection/ hepatitis C

4. Resolving acute gastroenteritis

THANK YOU