general medicine internal assessment

General medicine bimonthly assessment

Kundana 

Roll no:60

3rd semester

I have been given the following assignment in an attempt to read,comprehend,analyze,reflect upon and discuss captured patient centered data.

This is the link given to me regarding cases:-

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

Question 1)

Long case:-

• It is a case of 44 year old male presented with a 3 day history of anasarca and decreased urine output
• Completeness:- the case was depicted in detailed manner and all the required history was taken , all the investigations were done everything was explained clearly
• Correctness:- the data presented was accurate
• Diagnosis:- the patient has bilaterally symmetrical chronic progressive erosive peripheral polyarthritis
• Final diagnosis:- Acute glomerulonephritis,due to secondary Amyloidosis 

Short case:-1

• It is a case of 49 year old lecturer presented with a 2 month history of progressive asymmetric involuntary movements of his right index and middle fingers.
• Completeness: The case was complete with all the required details , examination and investigations
• Correctness:- the data presented was accurate
• The diagnosis was concluded based on symptomatology,examinations and investigations that were done
• Final diagnosis:- idiopathic Parkinson’s disease stage 1 denovo HTN and multiple system atrophy -Parkinsonian type (MSA-P)

Short case:-2

• It is the case of  19 year old male resident of nalgonda with tinea corposis and Iatrogenic Cushing’s syndrome
• Completeness:- The case was complete with all the required details, examination and investigations 
• Correctness:- the data presented was accurate 
• The diagnosis was concluded as Iatrogenic cushings syndrome, tinea corporis,Denovo HTN
• Final diagnosis:- Iatrogenic Cushing’s syndrome secondary to topical clobetasol application all over the body for approximately one year, Tinea corporis,denovo HTN

Question 2 and 3)

Long case: It is a case of 44 year old male , presented with 3 day history of anasarca and decreased urine output 

• Problem list:- chief compliant of 3 day history of bilaterally symmetrical rapidly progressive generalised edema
• Frothing of urine but no hematiria with gradually decreased urine output over past 3 days
• Patient reported since 2011, he had severe joint pains which are asymmetric and gradually become bilaterally symmetrical and involving small joints of his hands and wrist
• There is even difficulty in holding a cup of tea or glass of water , pain in his finger joints and wrist while brushing and pain holding mug while bathing and pain in toss and ankles on both sides when walking
• He is even having early morning pains and limitation of movement in his hands,wrists and feet which last for about an hour , reported pains and limitation of movements improved with activity 
• He developed subcutaneous swellings in the proximal joints of his fingers.He had involuntary weight loss and loss of appetite 
• He has burning sensation in his eyes with increased tearing but no visual deficits
• He had bilateral, purplish reticular markings on sclera of both eyes . Palpebral conjunctival pallor and bilateral periorbital puffiness present
• He had leukonychia and bilateral pitting type pedal edema present which was extending upto middle of legs
• He had problems of swelling,erythema,mild pain and limitation of active and passive movements in different parts of axial and appendicular skeleton

The investigations that were done are x-ray of hands and wrists from which osteopenia and erosions of MCP and PIP joints 

Chest X-ray :- right border shows mildly dilated right atrium , left heart border shows prominent aortic knuckle

Urine microscopy showed dysmorphic RBC s and occasional pus cells

Diagnostic approach of case study:- Acute glomerulopathy with bilaterally symmetric chronic progressive erosive peripheral polyarthritis, including secondary hypertension,oliguria(360 ml/24 hours),hypoalbuminea (serum albumin 2.5g/dl) and anasarca, dysmorphic RBCs in urine

REVIEW OF LITERATURE:-

• Few studies show that urinary dysmorphic RBCs were 92.7%sensitive and 100% specific for a biopsy confirmed diagnosis of glomerulonephritis
• Problem representation for this patient and insight into the sequence of his life events provide clues that current accurate problem could be a sequel of his long term, poorly treated cheonic problem

Differential diagnosis:-

• Rheumatoid arthritis with gout
• Psoriatic arthritis 
• Enteropathic arthritis
• Reactive arthritis 
• SLE

Final diagnosis:- Acute glomerulonephritis,likely due to secondary amyloidosis due to chronic poorly treated seronegative erosive Rheumatoid arthritis 

Dilutional hyponatremia secondary to anasarca due to glomerulonephritis 

Treatment:-

Free water restriction for Hyponatremia

Tab.PREDNISOLONE P/O 20 mg OD

Tab.FEBUXOSTAT P/O 80 mg OD

Haemodialysis for worsening renal dysfunction 

Short case 1:- it is a case of lectures with 2 month history of progressing asymmetric  involuntary movements of his right index and middle fingers

• Problem list:- progressive asymmetric involuntary movements of his right index and middle fingers 
• Movements are involuntary,rhythmic to and fro oscillations
• He has difficulty in walking and walk with small short steps and forword stoop
• He is been speaking in a monotonous drab since 2 months
• He has hypertonia in his right wrist
• There were involuntary movements like resting tremors of right uppe rlimb with high anplitude 
• Microphagia was present
• Postural hypotension and erectile dysfunction present

Investigations:- 

• ECG show sinus tachycardia with pseudo infarct pattern in leads I and aVL with dagger q waves in same leads 

•2D echo shows grade II diastolic dysfunction 

Diagnosis:- 

-Idiopathic parkinson’s disease stage-I with denovo HTN

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

Treatment:-

Tab.Syndopa plus 125 mg QID 

Tab.syndopa 125 mg CR OD

Tab.tea 40 mg OD

Short case 2:- case of Iatrogenic Cushing’s syndrome and tinea corporis

• Problem list:- itchy ring lesions over arms, abdomen, thigh and groin since 1 month 
• Purple stretch marks over abdomen,lower back,upper limbs 
• Abdominal distention and facial puffiness
• Pedal edema
• Low back ache
• Feeling low 
• Weight gain and loss of libido
• Pitting edema upto knee
• Moon face, pink striae , gynecomastia, buffalo hump,sparse scalp hair 

Investigations:-

•CBP,TLC,PLT,CUE in which albumin is +1, pus cells 3-4, LFT ,RFT, albumin,serum creatinine , electrolytes  tests are done

Provisional diagnosis:-

Iatrogenic Cushing’s syndrome,tinea corporis, denovo HTN 

Final diagnosis:-

Iatrogenic Cushing’s syndrome secondary to topical clobestol application all over one year , tinea corporis , denovo HTN

Question 4) 

I havent get a case yet i will update when i get one

Question 5)

• We are having online theory and clinical classes since 3 months due to covid pandemic 
• We haven’t had a chance to visit hospital and interact directly with the patients in our online classes
• By these online blogs we are able to discuss patient cases with our interns and their problems with probable diagnosis 
• After 3 months of pandemic we came to our institutions back so we are able to visit the hospital again and we are able to interact with patients taking their history with the help of our intern
• We are very helpful with these clinical cases and they are knowledgeable 
• We are taking history by our own and transforming it into e logs was actually super exciting 
• All these opportunities were made possible by our General medicine department professor  Dr.Rakesh Biswas and respective interns assigned to us and PG s