BLENDED BIMONTHLY ASSESSMENT

 

G. NANDINI

ROLL NO : 38 , 3 RD SEM

QUESTION 1:

LONG CASE:

LINK: 

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

  

This long case presentation is very nice even a 2 nd year mbbs student can understand the case very well. Because in the case first everything that patient said is written in his words and next the cause for each and every symptom is explained in his words and from that a provisional diagnosis is made and if it's the provisional diagnosis to confirm it what are the features we should look into is explained in detailed manner. Then all inspection  findings  are seen in the photographs that attached in the log. Which is very good because anyone who look the log can easily understand how the patient actually presented to opd. The very beautiful thing in this is he also explained the x-ray of the patient and we can understand much better due to this and then Disscussed about diagnostic approach with all scientific proof for his diagnosis .Finally he made a diagnosis of the disease. I think that the diagnosis is very accurate because he explained everything with a reason behind it and with a scientific approach towards a problem. The pedagogic questions are also answered very well with complete answers and required data. The very good thing is that in the log he also mentioned the references which makes us easy to find out things related to the data he had put up in this log.

SHORT CASE 1 :

The short is represented in very nice manner. Every thing is written in detail in patient words. All investigations were done. Since the patient has problem with CNS, all the tests to access his CNS are done. In this case many tests are done to know where actually the problem is present. With the given details. From  the details I also made a provisional diagnosis that the case is of parkinsonism so I think the case is described in a detailed manner that is the reason I also made a correct provisional diagnosis. But the pictures or video of the patient should have uploaded. 

SHORT CASE 2 :

This is a short case of cushings syndrome . This case is also presented very well. The updates in the case is present so that we are able to understand whether the patient is responding to the medication or not and the pictures posted were very clearly explaining that he is suffering from cushings syndrome. The pictures were nice and  by reading the case I understand how to approach the case and based on symptoms how we should refer to other departments. 

QUESTION 2:

LONG CASE :

PROBLEM LIST :

A 44 year old man presented with a 3-day history of bilaterally symmetrical rapidly progressive generalized edema.He reported frothing of urine but no haematuria

Prior to this, the patient reported that since 2011, he had severe joint pains, which were initially asymmetric and gradually became bilaterally symmetrical and involving the small joints of his hands and wrist. The joint pains were associated with significant local edema, and painful limitation of movements. 

Localisation of Acute Problem

Anasarca and frothy urine with decreasing urine output suggest a renal pathology. Proteinuria causing anasarca likely due to glomerular pathology. Other systemic causes like heart failure and liver dysfunction can be ruled out due to absence of dyspnea, palpitations, bendopnea or syncope. Liver dysfunction can be ruled out by lack of jaundice, melaena or hematemesis (from bleeding varices), and abdominal distention not occurring prior to pedal edema.

Within the kidney, pre-renal and post-renal causes can be effectively ruled out from the absence of volume loss (vomiting, diarrhea, diuretic abuse or burns) and no history of acute retention of urine or lower urinary tract symptoms (LUTS) like frequency, urgency, hesitancy or precipitancy. The presence of frothy urine and edema strongly supports a glomerular pathology due to significant loss of protein and also decreased urine output. Isolated defects in tubular/interstitium are unlikely as such patients have a deficit in maintaining urinary concentration, which causes polyuria. Such a high range of proteinuria causing anasarca is also not seen with tubular/interstitial pathologies alone.

Localisation of Chronic Problem

This 44 year old man has a 10 year history of bilaterally symmetrical progressive inflammatory polyarthritis. Features favouring an inflammatory pathology are -

1. Features of inflammation such as severe pain associated with edema of the joints and limitation of range of active movements
2.  Early morning stiffness, lasting for more than 30 mins (for 1 hour in this patient)
3. Pain and edema of joints improving with activity and worsening with rest
4. Features of uncontrolled systemic inflammation such as fever, involuntary loss of weight associated with loss of appetite.
5. Swellings at joints and deformation of normal joint posture 

Treatment

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 :

PROBLEM LIST :

A 49 year old English and Telugu language lecturer presented with a 2 month history of progressive asymmetric involuntary movements of his right index and middle fingers.They were not troublesome initially but for the past 2 months he has been unable to correct answer sheets because of the involvement of his thumb and maintaining stability of his hand was proving difficult. He describes these movements as involuntary, rhythmic to and fro oscillations.

At this point, he also says that his walking has become difficult with small, short steps and a forward stoop, and he feels that although he weighs 60 kgs. he feels like it weighs 100 kgs. 

he reports that he has been having difficulty in taking stairs up, in that he feels he sometimes might lose balance. 

provisionally diagnosed with 

1. Idiopathic Parkinson's Disease Stage 1 with denovo HTN.

2. 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

SHORT CASE 2 :

19 year old male resident of Nalgonda and currently studying intermediate ,came to opd with complaints of :

-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 .

FINAL DIAGNOSIS : 

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

TINEA CORPORIS

DENOVO HTN

We took dermatologist opinion for tenia corporis where they advised 

Ointment AMLORFINE 

FUSIDIC ACID CREAM.

SALINE COMPRESS OVER LEISONS.

Plan to start anti fungals on next visit once dose of steroids is reduced .

OPTHAL opinion Was taken to look for visual acuity and cataract .

No features of lens opacities noted .

BUT IOP was high ,where they advised to follow up .

We advised pt to get fasting  8am serum cortisol levels and was planned to start on low dose steroids to avoid adrenal crisis.

8AM S CORTISOL LEVELS (30/5/21)

- 0.46 mcg/dl ( very low) .

( normal range - 4.3-22.4 mcg/dl).

In view of lvh pt was started on tab telma 20 mg od .

On 3/6/21 - ACTH STIMULATION TEST WAS DONE .

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

1 HR LATER FASTING SERUM CORTISOL SAMPLE WAS SENT .

VALUE - 0.73 mcg/dl 

Indicating there was HPA AXIS suppression and pt was started on TAB HIZONE 15 mg per day in three divided doses @ 8am ,12 pm and 4 pm.

Pt was asked to follow up after one month .

QUESTION 3:

LONG CASE OF ACUTE GLOMERULONEPHRITIS :

Acute glomerulonephritis is a syndrome characterized by the abrupt onset of hematuria often accompanied by proteinuria, hypertension, edema, and renal dysfunction. Acute glomerulonephritis can be subdivided into primary glomerular disease, postinfectious glomerulonephritis, and glomerulonephritis associated with systemic disease. With few exceptions, the underlying mechanism of acute glomerulonephritis is an immunologic one. To differentiate clinically the specific etiology of the glomerulonephritis, attention must be focused on the presence of signs or symptoms of systemic disease, changes in the environment of the patient, family history of renal disease, and recent history of infectious disease.

SHORT CASE 1:

PARKINSONISM :

Symptoms

Parkinson's disease signs and symptoms can be different for everyone. Early signs may be mild and go unnoticed. Symptoms often begin on one side of your body and usually remain worse on that side, even after symptoms begin to affect both sides.

Parkinson's signs and symptoms may include:

• Tremor. A tremor, or shaking, usually begins in a limb, often your hand or fingers. You may rub your thumb and forefinger back and forth, known as a pill-rolling tremor. Your hand may tremble when it's at rest.
• Slowed movement (bradykinesia). Over time, Parkinson's disease may slow your movement, making simple tasks difficult and time-consuming. Your steps may become shorter when you walk. It may be difficult to get out of a chair. You may drag your feet as you try to walk.
• Rigid muscles. Muscle stiffness may occur in any part of your body. The stiff muscles can be painful and limit your range of motion.
• Impaired posture and balance. Your posture may become stooped, or you may have balance problems as a result of Parkinson's disease.
• Loss of automatic movements. You may have a decreased ability to perform unconscious movements, including blinking, smiling or swinging your arms when you walk.
• Speech changes. You may speak softly, quickly, slur or hesitate before talking. Your speech may be more of a monotone rather than have the usual inflections.
• Writing changes. It may become hard to write, and your writing may appear small.

Medications your doctor may prescribe include:

• Carbidopa-levodopa. Levodopa, the most effective Parkinson's disease medication, is a natural chemical that passes into your brain and is converted to dopamine.

  Levodopa is combined with carbidopa (Lodosyn), which protects levodopa from early conversion to dopamine outside your brain. This prevents or lessens side effects such as nausea.

  Side effects may include nausea or lightheadedness (orthostatic hypotension).

  After years, as your disease progresses, the benefit from levodopa may become less stable, with a tendency to wax and wane ("wearing off").

  Also, you may experience involuntary movements (dyskinesia) after taking higher doses of levodopa. Your doctor may lessen your dose or adjust the times of your doses to control these effects.

• Inhaled carbidopa-levodopa. Inbrija is a new brand-name drug delivering carbidopa-levodopa in an inhaled form. It may be helpful in managing symptoms that arise when oral medications suddenly stop working during the day.

• Carbidopa-levodopa infusion. Duopa is a brand-name medication made up of carbidopa and levodopa. However, it's administered through a feeding tube that delivers the medication in a gel form directly to the small intestine.

  Duopa is for patients with more-advanced Parkinson's who still respond to carbidopa-levodopa, but who have a lot of fluctuations in their response. Because Duopa is continually infused, blood levels of the two drugs remain constant.

  Placement of the tube requires a small surgical procedure. Risks associated with having the tube include the tube falling out or infections at the infusion site.

• Dopamine agonists. Unlike levodopa, dopamine agonists don't change into dopamine. Instead, they mimic dopamine effects in your brain.

  They aren't as effective as levodopa in treating your symptoms. However, they last longer and may be used with levodopa to smooth the sometimes off-and-on effect of levodopa.

  Dopamine agonists include pramipexole (Mirapex), ropinirole (Requip) and rotigotine (Neupro, given as a patch). Apomorphine (Apokyn) is a short-acting injectable dopamine agonist used for quick relief.

  Some of the side effects of dopamine agonists are similar to the side effects of carbidopa-levodopa. But they can also include hallucinations, sleepiness and compulsive behaviors such as hypersexuality, gambling and eating. If you're taking these medications and you behave in a way that's out of character for you, talk to your doctor.

• MAO B inhibitors. These medications include selegiline (Zelapar), rasagiline (Azilect) and safinamide (Xadago). They help prevent the breakdown of brain dopamine by inhibiting the brain enzyme monoamine oxidase B (MAO B). This enzyme metabolizes brain dopamine. Selegiline given with levodopa may help prevent wearing-off.

  Side effects of MAO B inhibitors may include headaches, nausea or insomnia. When added to carbidopa-levodopa, these medications increase the risk of hallucinations.

  These medications are not often used in combination with most antidepressants or certain narcotics due to potentially serious but rare reactions. Check with your doctor before taking any additional medications with an MAO B inhibitor.

• Catechol O-methyltransferase (COMT) inhibitors. Entacapone (Comtan) and opicapone (Ongentys) are the primary medications from this class. This medication mildly prolongs the effect of levodopa therapy by blocking an enzyme that breaks down dopamine.

  Side effects, including an increased risk of involuntary movements (dyskinesia), mainly result from an enhanced levodopa effect. Other side effects include diarrhea, nausea or vomiting.

  Tolcapone (Tasmar) is another COMT inhibitor that is rarely prescribed due to a risk of serious liver damage and liver failure.

• Anticholinergics. These medications were used for many years to help control the tremor associated with Parkinson's disease. Several anticholinergic medications are available, including benztropine (Cogentin) or trihexyphenidyl.

  However, their modest benefits are often offset by side effects such as impaired memory, confusion, hallucinations, constipation, dry mouth and impaired urination.

• Amantadine. Doctors may prescribe amantadine alone to provide short-term relief of symptoms of mild, early-stage Parkinson's disease. It may also be given with carbidopa-levodopa therapy during the later stages of Parkinson's disease to control involuntary movements (dyskinesia) induced by carbidopa-levodopa.

  Side effects may include a purple mottling of the skin, ankle swelling or hallucinations. 

SHORT CASE 2:

CUSHINGS SYNDROME:

SYMPTOMS:

The signs and symptoms of Cushing syndrome can vary depending on the levels of excess cortisol.

Common signs and symptoms of Cushing syndrome

• Weight gain and fatty tissue deposits, particularly around the midsection and upper back, in the face (moon face), and between the shoulders (buffalo hump)
• Pink or purple stretch marks (striae) on the skin of the abdomen, thighs, breasts and arms
• Thinning, fragile skin that bruises easily
• Slow healing of cuts, insect bites and infections
• Acne
• SIGNS AND SYMPTOMS THAT WOMEN WITH CUSHINGS SYNDROME EXPERIENCE:
• Thicker or more visible body and facial hair (hirsutism)
• Irregular or absent menstrual periods
• OTHER SIGNS AND SYMPTOMS THAT MEN WITH CUSHINGS SYNDROME EXPERIENCE:
• Decreased sex drive
• Decreased fertility
• Erectile dysfunction
• OTHER POSSIBLE SIGNS AND SYMPTOMS OF CUSHINGS SYNDROME:

• • Severe fatigue
  • Muscle weakness
  • Depression, anxiety and irritability
  • Loss of emotional control
  • Cognitive difficulties
  • New or worsened high blood pressure
  • Headache
  • Infections
  • Skin darkening
  • Bone loss, leading to fractures over time
  • In children, impaired growth

QUESTION 4 :

https://38nandinigandla.blogspot.com/2021/08/general-medicine-e-log_14.html

QUESTION 5 :

The experience of making is log is very good but and also helpful in knowing new terms used in medicine.But it would be better if we take the history from the patient directly than just making elog by the reports and data collected by interns. But I think the advantage by making this elog is that we can have the patient data safely  and we can use these cases to make studies and find out new things as we have lot of data.