He was in his late fifties, a known case of vitiligo for the past 12 years who was admitted to surgical ward for dysphagia for 10 days. More difficult on swallowing solid than fluid. It wasn't preceded by abdominal pain and there was no constitutional symptom. No family history of cancer. Neither does he smoke nor drink.
It was unlikely oesophageal carcinoma in such acute presentation. Reflux oesophagitis or ulceration causing stricture is possible but there was no symptom pointed towards it. So oesophageagastroduodenoscope was indicated to look for the direct cause of dysphagia. Barium swallow was arranged too but patient would have problem in swallowing.
Here's how the story starts...
He refused to lie down in scope room claimed to have shortness of breath in supine position. Oh well, he had been sit sleeping for the past 4 days. Medical referral made but work out elicited no cardiac or pulmonary related dyspnea. He appeared comfortable and oxygen saturation was always perfect under room air. His big bunch of family members were around everyday and they take turn to massage him. So I, evil enough, put him a PSY label - feigning and attention seeking.
One fine day, another medical referral was made. This time around, a physician came to review instead. He solved the mystery just by a sentence:
"Pakcik, tengok saya!"
Slowly, the patient lifted up head with much struggle, and dropped down again shortly. He had droopy eyelids and proximal myopathy on examination.
Yes, he was in head-nodding position most of the time, which I didn't bother to find out why.
"So what's the diagnosis?" We were asked.
"Myasthenia gravis..." We stared dumfoundedly. It never even cross my mind.
Further history was elicited that his muscle weakness started months ago, worst towards evening. And his son is diagnosed myasternia gravis too on treatment!
Thinking about it, everything seems to be co-related:
I feel a bit dumb.
Lesson of the day:
1) Think wide! Surgery posting doesn't mean diagnosing only surgical related problem.
2) Do not judge!
It was unlikely oesophageal carcinoma in such acute presentation. Reflux oesophagitis or ulceration causing stricture is possible but there was no symptom pointed towards it. So oesophageagastroduodenoscope was indicated to look for the direct cause of dysphagia. Barium swallow was arranged too but patient would have problem in swallowing.
Here's how the story starts...
He refused to lie down in scope room claimed to have shortness of breath in supine position. Oh well, he had been sit sleeping for the past 4 days. Medical referral made but work out elicited no cardiac or pulmonary related dyspnea. He appeared comfortable and oxygen saturation was always perfect under room air. His big bunch of family members were around everyday and they take turn to massage him. So I, evil enough, put him a PSY label - feigning and attention seeking.
One fine day, another medical referral was made. This time around, a physician came to review instead. He solved the mystery just by a sentence:
"Pakcik, tengok saya!"
Slowly, the patient lifted up head with much struggle, and dropped down again shortly. He had droopy eyelids and proximal myopathy on examination.
Yes, he was in head-nodding position most of the time, which I didn't bother to find out why.
"So what's the diagnosis?" We were asked.
"Myasthenia gravis..." We stared dumfoundedly. It never even cross my mind.
Further history was elicited that his muscle weakness started months ago, worst towards evening. And his son is diagnosed myasternia gravis too on treatment!
Thinking about it, everything seems to be co-related:
Vitiligo
Head-nodding position
Massage
Dysphagia
Shortness of breath
Head-nodding position
Massage
Dysphagia
Shortness of breath
I feel a bit dumb.
Lesson of the day:
1) Think wide! Surgery posting doesn't mean diagnosing only surgical related problem.
2) Do not judge!
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