Inavolu Akhila

 GENERAL MEDICINE BIMONTHLY  ASSESSMENT 

- AUGUST  21

I.Akhila

3rd sem

I have been given the following cases to solve in an attempt to understand the topic of  'PATIENT CLINICAL DATA ANALYSIS' to develop my competency in reading and comprehending clinical data including history taking,clinical findings,investigations and diagnosis and come up with a treatment plan.

This is the link to the questions asked in the assignment:

https://medicinedepartment.blogspot.com/2021/08/medicine-paper-for-aug-2021-bimonthly.html?m=1

Below are the answers to the MEDICINE ASSIGNMENT based on my comprehension of the cases.

QUESTION 1 :

https://2018-21batchpgy3gmpracticals.blogspot.com/2021/08/18100006003-case-presentations.html?m=1

Please go through the long and short cases in the first link shared above and provide your critical appraisal of the captured data in terms of completeness, correctness and ability to provide useful leads to analyze the diagnostic and therapeutic uncertainties around the cases shared.

Long case : A case of acute glomerulonephritis  , due to sec. amyloidosis due to chronic poorly treated seronegative erosive rheumatoid arthritis .

Completeness :   The E-log was complete in all factors . It included chief complaints , present history , past history , medical/surgical history , personal history , family history , social & educational history , immunization history .

           This elog had everything one could have asked for ; for a better understanding of the case and to treat in a better way .

Review on the case :

The case was beautifully presented in detail , which is almost closely knit with his details , which seemed like a story to me , like a step-to-step detailed explanation .

Evolution of symptomatology was described in a detail manner .

There was also a detailed explanation of the patient's acute and chronic problem .

General examination was done in a much detailed way ; in different positions with clear documentation .

Clinical images of the patient and investigations were added with deidentification .

 Systemic examination with detailed inspection , palpation , range of movements was explained .

Diagnostic approach and treatment was also well explained .

 Correctness : All the data provided in the E-log is correct .

👉 short case 1 : Idiopathic Parkinson's disease stage 1 with denovo HTN & multiple system atrophy - parkinsonian type ( MSA-P )

Completeness : The elog was complete . it included chief complaints , history of presenting illness , history of past illness , medical / surgical history , personal history , family history , social & education history , immunization history.

Review on the case:

The case was beautifully presented in detail , which is almost closely knit with his details , which seemed like a story to me , like a step-to-step detailed explanation .

Evolution of symptomatology was described in a detail manner 

CNS examination was described extremely well with all detailed documentation of reflexes etc.

Clinical images of the patient and investigations were added with deidentification .

 Correctness : All the data pirovided in the E-log is correct .

👉 short case 2 : Iatrogenic cushings syndrome secondary to topical clobetasol application all over the body for approx. 1 yr.

Completeness :  this elog was little incomplete acc. to me as it didn't include his past history , family history , treatment history , personal history .

Review on the case:

Evolution of current symptomatology was described beautifully .

De-identified clinical images in the presentation , showed us the condition of the pt. clearly .

His follow up details were also neatly documented .

 Correctness : All the data provided in the E-log is correct .

QUESTION 2 

Please Analyze the above linked long and short cases patient data by first preparing a problem list for each patient in order of perceived priority (based on the shared data) and then discuss the diagnostic and therapeutic uncertainty around solving those problems. 

ANSWER : 

Long case :

Problem list - 

-generalized edema

-facial puffiness with pedal edema 

-bilaterally symmetric, pitting type pedal edema

-breathlessness, palpitations or chest pain

-frothing of urine 

-decreasing urine output

-severe joint pains

weight loss and loss of appetite 

-subcutaneous swellings in proximal joints of his fingers 

-proteinuria causing anasarca

DIGNOSIS :

-Acute Glomerulopathy (Glomerulonephritis/Nephrotic syndrome)

 

-Bilaterally Symmetric Chronic Progressive Inflammatory Peripheral Polyarthritis

-Acute Glomerulonephritis, likely due to Secondary Amyloidosis due to Chronic Poorly Treated Seronegative Erosive Rheumatoid Arthritis.

Dilutional Hyponatremia secondary to Anasarca due to Glomerulonephritis

Hyperuricemia likely due to decreased Uric Acid Excretion Precipitating Gouty Arthritis

Anemia of Chronic Disease secondary to Poorly Treated Rheumatoid Arthritis

TREATMENT PLAN :

1.Free water restriction for Hyponatremia

2. Tab. PREDNISOLONE P/O 20 mg OD

3.Tab FEBUXOSTAT P/O 80 mg OD

4.Haemodialysis for worsening renal dysfunction.

SHORT CASE 1 :

PROBLEM LIST :

-progressive asymmetric involuntary movements of his right index and middle fingers.

- Stiffness in his wrist (right >left), now ascended to his elbows

-involuntary movements started appearing in his left hand too

-Walking became difficult with small short steps and forward stoop 

-Difficulty in taking up stairs 

-swaying of his  trunk while walking

-overshooting his hand while picking objects 

-Hasn't been having morning erections since 2 months and loss of sexual desire

-since 2 months his bowel habits have been incredibly erratic, in that he sometimes immediate urge to defecate and sometimes goes 2-3 days with constipation 

-has been speaking in monotonous drab since 2 months

DIAGNOSIS 

-idiopathic parkinson's disease stage - 1 with denovo HTN 

-Multiple system atrophy - parkinsonian type (MSA - P) 

Treatment:

1. Tab. Syndopa Plus 125 mg QID

2. Tab. Syndopa 125 mg CR OD

3. Tab. Telma 40 mg OD

Problem list:

-Itchy Ring leisons over arms ,abdomen ,thigh and groin since 1 and half year .

-Purple stretch marks all over abdomen ,lower back ,upper limbs ,thighs since 1 year .

-Abdominal distension and facial puffiness since 6 months.

- Pedal edema since 3 months.

- Low back ache since 3 months .

- Feeling low , not feeling to talk to anyone.

- Weight gain and decreased libido since 3months.

- Loss of libido and erectile dysfunction since 2 months .

Multiple hyperpigmented plaques over lower limbs and abdomen 

-Easy fatigue, weakness and lower backache 

-Moon face present, thick skin 

-poor healing over leg ulcers 

-Acne present over face 

-Acanthosis nigrans noted over neck 

-GYNECOMASTIA PRESENT 

-Buffalo hump present 

-Sparse scalp hair 

-Difficulty in  getting up from chair

DIAGNOSIS :

-IATROGENIC CUSHINGS SYNDROME SECONDARY TO TOPICAL CLOBETASOL APPLICATION ALL OVER BODY FOR APPROXIMATELY ONE YEAR.

-TINEA CORPORIS

-DENOVO HTN .

TREATMENT PLAN :

-Ointment AMLORFINE 

-FUSIDIC ACID CREAM.

-SALINE COMPRESS OVER LEISONS

-Tab.Telma 20 mg od - due to low cortisol level

- TAB HIZONE 15 mg per day in three divided doses @ 8am ,12 pm and 4 pm.

-0.4 ML OF ACTOM PROLONGATUM INJECTION (ACTH) INTRA MUSCULAR  @ 7am

-Tab Shelcal 500 OD and Tab Vit D 3 Od.

-Tab ULTRACET /PO/SOS.

-Tab Itraconazole 100 mg bd. And lulifin cream and tab levocitrixine 5mg od.

QUESTION 3

Testing competency in "Evidence based medicine": Include the review of literature around sensitivity and specificity of the diagnostic interventions mentioned and same around efficacy of the therapeutic interventions mentioned for each patient. 

Long case:

Investigations done are:-

Current Admission - Blood tests

Blood work from previous presentations to hospital. RA factor was negative

24hrs urinary protein: 1500 mg

24hrs urinary creatinine: 0.8

Urine Microscopy - Freshly voided urine sample was centrifuged at high speed (> 2700 RPM) and sediment collected and fixed on glass slide and examined under microscope at 400 (10x * 40x) showed DYSMORPHIC RBCs (black circles) and occasional pus cells (red circles). Dysmorphic RBCs were those that had altered shape, microcytic or with membrane defects.

Efficacy of Treatment given:-

Tab. PREDNISOLONE P/O 20 mg OD:-It is used to treat conditions such as arthritis, blood problems, immune system disorders, skin and eye conditions, breathing problems, cancer, and severe allergies. It decreases your immune system's response to various diseases to reduce symptoms such as pain, swelling and allergic-type reactions.

Tab FEBUXOSTAT P/O 80 mg OD:-class of medications called xanthine oxidase inhibitors. It works by decreasing the amount of uric acid that is made in the body. Febuxostat is used to prevent gout attacks but not to treat them once they occur.

Haemodialysis for worsening renal dysfunction

Short case-1

Investigations done are:-

ECG:-Shows Sinus Tachycardia with pseudo infarct pattern in leads I and aVL with dagger q waves in the same leads,No late intrinsicoid deflection of R wave with modified Cornell criteria showing LVH.

2 D Echo :-Grade II diastolic dysfunction

Efficacy of Treatment given:-

Tab. Syndopa Plus 125 mg QID:- is a combination of two medicines used to treat Parkinson's disease. It is one of the most effective medications to relives symptoms of Parkinson's disease such as tremor, muscle stiffness and difficulty moving.

Tab. Syndopa 125 mg CR OD:-is a combination of two medicines: Levodopa and Carbidopa. This medication is used to treat the symptoms of Parkinson's disease like tremors , stiffness and slowness of movement.

 Tab. Telma 40 mg OD:- is a medicine used to treat high blood pressure and heart failure. Lowering blood pressure helps to prevent future heart attack and stroke. 

Short case -2

Investigations done are:-

CBP - HB - 13.4 g/dl 

TLC - 6,800

PLT - 1.5 lakhs.

RBS - 139 mg/dl 

CUE - ALBUMIN - +1 

SUGARS - NIL .

PUS CELLS - 3-4 

RBC - NIL .

LFT - TB -1.03

DB-0.21

ALBUMIN - 3.9

RFT - UREA - 22 

SERUM CREATININE -0.6

ELECTROLYTES - NA - 136 

K- 4 

CL-98 

USG ABDOMEN - NORMAL.

ECG - SINUS TACHYCARDIA 

LVH PRESENT.

Efficacy of Treatment given:-

Tab.Telma 20 mg od - due to low cortisol level

 TAB HIZONE 15 mg:- is prescribed for Severe allergic reactions,Allergic conditions,Cancer,Skin disorders,Eye disorders.

Tab Shelcal 500 OD and Tab Vit D 3 Od:-To treat vitamin D and Calcium deficiency.

Tab ULTRACET /PO/SOS:-is a combination of two medicines that are used for short term relief of pain, inflammation, and swelling in conditions that affect joints and muscles. 

Tab Itraconazole 100 mg bd.:-to treat a variety of fungal infections.

Tab levocitrixine 5mg od.:-relieve runny nose, sneezing, and redness, itching.

QUESTION-4

Share the link to your own case report this month of a patient that you connected with and engaged while capturing his her sequential life events before and after the illness and clinical and investigational images along with your discussion of that case.

I didn't get a chance to do any case blog yet

QUESTION-5

competency in  

logging reflective observations on your concrete experiences of this last month

Reflective logging  of one's own experiences is a vital tool toward competency development in medical education and research.

-It's been two months into our second year and So far from the clinical postings we have learnt how to take a proper, complete history, understanding the disease and its diagnosis, treatment and also the way of communication with the patient. the every E log and and every case are very useful for us to understand and get a clarity on patient centered data and treatment for the patient.