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Offline Rayaan2

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Case (57)
« on: September 16, 2009, 06:49:15 AM »
 ;D ;Dfemale 65ys old present wth sever fatigability palpitations soreness of tongue numbness ang tingling sensation of the hands and feet ,infrequent chest pain with walking and dizzness
there was no history of jaundice ,blood transfusion ,or bilharziasis. she was nt takin any drugs
physical examination revealed mildly jaundice  pulse rate 120/min BP 160/80 cardiopulmpnary examination revealed ejection systolic murmur at left sternal edge . liver span was normal and the spleen was just palpable

increased tone of lower limbs with brisk knee reflexes,absence of ankle reflexes, equivocal planter reflexes,and impaired sensation of stocking disturbance


(1) what is the most likely diagnosis ?
(2)list five essential investigation?
(3)what is the couses of absent ankle reflex ?
(4)what treatment should be considered ?

                                                      its   my first time for participation so wish you best luck guys

Offline Kassim

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Re: Case (57)
« Reply #1 on: October 10, 2009, 11:33:14 AM »
(1)   what is the most likely diagnosis ?
megaloblastic  Anaemia, which is caused by  VB12, folic acid deficiency, Hypothyroidism, Alcoholism, and drugs that inhibit DNA replication.  Giving all the neurological symptoms the most likely diagnosis is VB12 deficiency.
Causes of vitamin B12 deficiency
•   Poor quality diet, vegetarian diet
•   Gastric causes - gastrectomy, congenital intrinsic factor deficiency
•   Intestinal causes - stagnant loop, congenital selective malabsorption, ileal resection, inflammatory bowel disease
•   Infestation - fish-tapeworm
•   Metabolic causes - transcobalamin II deficiency, nitrous oxide anaesthesia
•   Drugs causing decreased B12 levels - oral calcium-chelating agents, aminosalicylic acid, biguanides

(2)   List five essential investigations?
(a)   FBP: would like to know the Hgb level, if its low, then i know I m dealing with anaemia, to determine which type of Anaemia the next thing I will look at is MCV,‹ 70fl its microcytic anaemia, b/w 76-96fl normocytic, › 96fl then is Macrocytic Anaemia.
(b)    Blood film This may show macrocytic red cells, neutrophils with hypersegmented nuclei and Howell-Jolly bodies (residual fragments of the nucleus causing spherical blue-black inclusions on red blood cells seen on Wright-stained smears).

•   Biochemistry
o   There may be an increase in plasma unconjugated bilirubin (mildly jaundice)due to increased destruction of red-cell precursors in the marrow. Liver and thyroid function tests.
o   Serum vitamin B12 to establishing B12 deficiency. In general, levels < 150 pg/ml reliably indicate deficiency. Neurological deficiency or anaemia is usually evident in patients with levels < 120 pg/ml.
o   Folic acid levels to exclude deficiency, which may co-exist with B12 deficiency.
o   Autoantibody screen Intrinsic factor (IF) antibodies, if present, are virtually diagnostic of pernicious anaemia.
o   The Schilling test to differentiate whether B12 deficiency is due to pernicious anaemia or from an intestinal lesion causing malabsorption. It measures the absorption of B12 with and without intrinsic factor.
o   Gastroscopy to see if there is gastric atrophy and to exclude gastric cancer and polyps. Gastric cancer is two to three times commoner in patients with pernicious anaemia than in matched controls.
3) What is the couse of absent ankle reflex?
Features of vitamin B12 deficiency include peripheral neuropathy and Subacute Combined Denegation of the Cord with the resulting balance difficulties from posterior column spinal cord pathology. Since peripheral neuropathy is a Lower Motor Neurone Disease→ wasting, Faciculation, Hypotonia, reduced or absent Reflexes.
(4) what treatment should be considered ?
Will depend on the cause of the Anaemia,
For people with neurological involvement:
   Specialist  advice from a haematologist
   Initially hydroxocobalamin 1 mg intramuscularly on alternate days until there is no further improvement, then hydroxocobalamin 1 mg intramuscularly every 2 months.
   For people with NO neurological involvement:
o   Initially hydroxocobalamin 1 mg intramuscularly on alternate days for 2 weeks.
o   Maintenance dose, where the vitamin B12 deficiency is NOT thought to be diet related:
   The standard dose is to administer hydroxocobalamin 1 mg intramuscularly every 3 months for the rest of the person's life.
          Maintenance dose, where vitamin B12 deficiency is thought to be diet related:
   Advise people either to take oral cyanocobalamin tablets 50–150 micrograms daily between meals, or have a twice-yearly hydroxocobalamin 1 mg injection administered.
   In vegans this treatment may be needed for the rest of the person's life, whereas in other people with dietary deficiency, replacement treatment can be stopped once the vitamin B12 levels have been corrected and the diet has improved.
   Advise people to eat foods rich in vitamin B12. Foods which have been fortified with vitamin B12 (e.g. some soy products, and some breakfast cereals and breads) are good alternative sources to meat, eggs, and dairy products.

Hope this is the right answer.
Dr Kassim Shegow
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Offline Rayaan2

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Re: Case (57)
« Reply #2 on: January 05, 2010, 06:35:23 PM »
well done kassem


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