JULY i

JULY ASSESSMENT

Question 1

Case-1

Question 1: Competency tested for Peer to peer review and assessment : 

Please go through one student's entire answer paper frik kho kom this link, the one who is closest to your own roll number :

http://medicinedepartment.blogspot.com/2021/07/2019-batch-medicine-department-online.html?m=1

and share your peer review of each answer with your qualitative insights into what was good or bad about the answer. 

https://aksharakruthi.blogspot.com/2021/07/bimonthly-blended-assessment-for-june.html

1.case : https://amishajaiswal03eloggm.blogspot.com/

question : 1) What is the evolution of the symptomatology in this patient in terms of an event timeline and where is the anatomical localization for the problem and what is the primary etiology of the patient's problem?

Review:I agree with the diagnosis because the patient works in paddy fields so he is affected with the allergens in the paddy field .The flow chart answered in this question is appropriate and gives the  complete symptomatology .

My review-

This is a case of a patient with cervical Myelopathy.patient came to hospital with complaints of weakness of all 4 limbs preceeding alcohol binge and fall.

In the answers

Condition of Myelopathy hand is defined clearly and pyramidal tracts are also mentioned.. It would be better if used a picture of this condition. Finger escape condition is explained and the nerves and muscles involved are also explained. And how finger escape is seen in cervical Myelopathy is also explained. Hoff mans reflex is also explained.. The explanation part is good.. But if diagrams are inserted it would be much more easier for understanding.

2 .case : https://avulanikhil09.blogspot.com/

Question: could chronic alcohlism have aggravated the foot ulcer formation ?if yes and why ?

Review : the answer for this explained is true and due chronic alcoholism ➡️ diminished immune response ➡️leads to ulcers 

My review-

informative and easy to comprehend to the point answers and very brief ,the usage of flow charts and diagrams is well used the usage of text can be better and the overall elog was well written.

3. case:  https://bejugamomnivasguptha.blogspot.com/

Question :  Is there any relationship between occurrence of seizure to brain stroke. (3 m)

Review : it is obviously true that shock may lead to seizures .

Shock ➡️scar formation in brain ➡️it disrupt electrical signal ➡️it leads to seizures .so the explanation in this answer is exactly true 

My review-

Patient came to opd with chief complaints of palpitations, pedal oedema, chest heaviness, radiating pain along the left upper limb. Patient was diagnosed with cervical spondylosis and recurrent hypokalemic paralysis.

About the answers given..anatomical localisation is mentioned and primary etiology is discussed deeply.. And causes of the symptoms are explained and possibility of other diseases are mentioned. Tables are used to explain clearly.. Risk factors of hypokalemia are mentioned and ecg changes in hypokalemia are explained with diagram. Usage of tables and diagrams made this presentation a bit more effective.

4.case :https://daddalavineeshachowdary.blogspot.com/

Diagnosis : it is a case of  55 yr old female with viral pneumonia  secondary to covid 19 and Dm 

Review : The case discussion is very good and the treatment is explained in the right order .

My review-

This is a case of acute coronary syndrome. The patient came to OPD with shortness of breath . She is known case of HTN and DM. The review is very well written in the form of nice flow chart about her past illness to present illness. And risk factors of DM and HTN point to a cardiac origin is also explained. In the review indications and contradictions of PCI is very well explained. The patient is treated for all her symptoms.

Ioi

5.Case :https://budigesaikiran14.blogspot.com/

Diagnosis : alcohol induced cerebellar ataxia 

Review : Reasons for cerebellar ataxia is very well discussed .

It is due to damage to GABA -A receptor impaired glucose metabolism vit B1 deficiency .the way of answering a question is so attractive and it is easy to understand .

My review-

The symptomatology has been explained in a chronological order of occurrence.

The primary etiology of the patient has been mentioned with the necessary finding along with the pictorial representation.

The anatomical location of the problem has been described.

The mechanism of action was very well explained with the action of the pharmacological drugs administered.

The answers for the given questions were commendable along with the usage of statistics

6.case: https://aniganikavya06.blogspot.com/

 Diagnosis :Acute exacerbation of COPD associated with right heart failure and bronchiectasis.

Review :  What is the evolution of the symptomatology in this patient in terms of an event timeline and where is the anatomical localization for the problem and what is the primary etiology of the patient's problem?

 Anatomical Location of problem-Lungs- Bronchi and bronchioles

  Primary etiology- Usage of chulha since 20years

Answer explained is appreciable .every thing is really so point to point and easily understandable 

My review-In this answer the etiology of the patient's problem is COPD due to conseqeunce of using chulha but I think that the problem is also with allergy while she is working in the paddy fields. The patient is suffering from the shortness of breathing from long time due to the inhalation of smoke and that caused damage to the lungs,thus the patient is susceptable to the lung infections.

 In this link, the evaluation of symptomatology was explained well. Pharmacological and Non pharmacological interventions were mentioned but not in a detailed manner. The placebo effect was also not explained properly. I think the overall case and the answers to the questions could have been explained properly.

Case : 7 https://02shishirareddy.blogspot.com/

 Diagnosis : Alcohol induced dementia 

Review : Causes for electrolyte imbalance: 

                       Respiratory acidosis with metabolic alkalosis(due to renal compensation) in AECOPD patientswith chronic hypercapnia is the usual cause ofhypochloremia in these patient Commoncauses ofderanged serum sodium levels include hyperglycemia, use of thiazides or nonsteroidal anti-inflammatory drugs, congestive cardiac failure, chronic renal failure, and low dietary salt intake.

 Common causes of hypokalemia include diarrhea, laxative abuse, vomiting, certain diuretics, drugs like insulin, β2agonists, and theophylline.20 Thus, COPD patients per

se are predisposed to electrolyte imbalance. In turn electrolyte imbalance can cause respiratory muscle weakness, cardiac arrhythmia, low cardiac output. 

                    Thus the presence of electrolyte imbalance leads to significantly poor outcome among COPD patients.It is very interesting to know about the acidosis and very happy to read and get the knowledge about respiratory acidosis .it is really very helpful .

My review-

The history of present and past illness is coherent and well established. The videos are great for understanding the case. The case sheet has captured all the relevant data in the right order. Correct terminology was used. The reports of all the lab investigations conducted were given. The pharmacological intervention was elaborate and explained well. 

The symptomatology with anatomical localization and primary etiology was explained very well. The explanation was done with help of diagrams which made it easier to understand. The treatment part was also explained with all the drugs and injections that were given to the patient. The causes that are explained for acute exacerbation and for electrolyte imbalance were appropriate. At last all the questions were answered and case was handled well.

Case :8 https//savanthreddy.blogspot.com/

Diagnosis : INFECTIOUS DISEASE (Mucormycosis) 

Review : What are the postulated reasons for a sudden apparent rise in the incidence of mucormycosis in India at this point of time?

I think it is because of the use steroids in an uncontrolled manner.

COVID 19 is not the first disease where steroids are used as one of the main stay of treatment (in severe cases) but what has gone wrong in the recent time is even the lay man who got infected with Corona started using steroids right from the day 1 with no monitoring by a specialised physician.And they are not following any specific course of treatment.As many of them are also diabetic patients the are getting succumbed to mucormycosis.And it is not ending with mucormycosis but various other fungii are emerging to cause an epidemic.

And another reason for rise in mucormycosis cases may be the usage of tap water in oxygen concentrators.As most of the patients are being diagnosed of Covid in late stages in the second wave many of them Are requiring oxygen concentrators for supplemental oxygenation.And due to Lack of the people are using tap water instead of distilled water which serves as reservoir for the growth of mucormycosis.So this may be one of the reason for rise in mucormycosis cases. I feel really happy by reading this new information about the disease that is happening in our india and it is very well explained with the good image and reason behind the this epidemic 

My review-

Evolution of symptomatology was listed in a chronological order which was easy to understand. Only non-pharmacological interventions were explained, could have been better if pharmacological interventions were also included. The cause for acute exacerbation in this case was not explained in detail. Overall, the answers to the questions could have been answered in a  better way by adding some of the elements as mentioned above and explaining them in detail.

Case 9 : https://gsuhithagnaneswar.blogspot.com/?m=1

Diagnosis : cervical spondylosis Recurrent hypokalemic paralysis 

   Review : What are the reasons for recurrence of hypokalemia in her? Important risk factors for her hypokalemia? ➡️Since the patient complains of oedema the drugs used to relieve it such as diuretics can cause hypokalemia 

The patient also no albumin which is a cause for both oedema and hypokalemia 

The risk factors including 

1.    Alcohol use(excessive

2.    Chronic kidney disease

3.    Diabetic ketoacidosis

4.    Diuretics (water retention reliever

5.    Excessive laxative 

6.    Folic acid deficiency

7.    Primary aldosteronism  

8.    Some antibiotic uses 

It is point to point and easy everything is easily reviseble .happy to read about this new case 

My review-

The evolution of symptoms was explained in tabular form chronologically,it is quite good.Pharmacological and non-pharmacological interventions of each drug are explained with their mechanisms.But there are no pictures and flow charts.The journal link was also updated for more info.

Case 10 :   https://blendedasessmentmadhukumar.blogspot.com/

Diagnosis : inferior wall MI with uncontrolled sugars with k/c/o DM since 8yrs.

Review : What is the evolution of the symptomatology in this patient in terms of an event timeline and where is the anatomical localization for the problem and what is the primary etiology of the patient's problem?

➡️Chest pain- since 3days

Giddiness - since morning

Profuse sweating- since morning

Anatomical location of the lesion is inferior wall of the heart.

Etiology: 

Smoking

Diabetes mellitus

Hypertension

My review-

The symptomatology in the patient in terms of an event, based on timeline was explained properly. The pharmacological and Non-pharmacological interventions used by this patient were appropriate and in detail. All the questions were also answered but could have been listed the causes properly.

Q2-4

Patient centered data around the theme of renal failure patients with AKI, CKD and acute on CKD, 

captured by students from 2016 and 2019 batch in the links below

Patients with low back ache and renal failure

Q2) Share the link to your own case report 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. 

http://arunrollno46.blogspot.com/2021/07/aki.html

I have helped my juniors in taking histories and guided them in preparing elogs and presenting them in groups and in 2-4 sessions.

Q3) (Testing peer review competency of the examinees) :

Please go through the cases in the links 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.

AKI 

https://laharikantoju.blogspot.com/2021/07/58-year-old-male-patient-elog-lahari.html?m=1

Over view 

A 58 year old male patient came to casualty with chief complaints of:

- lower abdominal pain: 1 week

 -burning micturation:1week

- low back ache after lifting weights

-dribbling / decrease of urine out put:1week

-fever :1 week

- SOB , rest :1week  

  Apprisal

Case history was taken well and examination was very well done... Sequential evaluation of case is apprisiable 

Negative points 

It would be better if fever chart is added as it was treated with strict temp and IO monitoring as it would be better understood improvement of the case was not well mentioned

My Analysis

 This is a case of Acute kidney injury( AKI) 2° to UTI, associated with Denovo - DM -2

With ? Right HEART FAILURE,

With K/C/O - HTN ( Not on Rx)

-AKI causes a build-up of waste products in your blood and makes it hard for your kidneys to keep the right balance of fluid in your bodyand return of creatinine to the base line and symptoms less then 3 months indicating it to be a AKI

Acute on CKD :

http://srinaini25.blogspot.com/2021/07/srinaini-roll-no-33-3rd-semester-this.html

Over view 

A 75yr old male patient ,labourer by occupation ,came to casuality with Cheif complaints of 

• Lower backache since 10days

• dribbling of urine since 10days

• Pedal edema since 3days 

• SOB at rest since 3days 

• Increased involuntary movements of both upper limbs since 10days .

Apprisal

I would not find any points to be highlighted . History was taken well 

Negative points

There are no clinical pics of the symptoms like pedal edema.

Proper chronological order of symptoms apperance was not done 

Fever chart was not included.

No IO charting was done though it was told it should be strictly monitored

My Analysis

This is case of 

Acute renal failure (intrinsic)

 Grade 1 L4-L5 Spondylodiscitis, Multifocal infectious Spondylodiscitis

Hyperuricemia 2° to Renal failure 

Uraemia induced tremors( resolved)

Delerium 2° to septic /Uremic encephalopathy (resolving)

CKD :

https://krupalatha54.blogspot.com/2021/07/a-49-yr-old-female-with-generalized.html?m=1

Over view

A 49 yr old female , mother of 2 children, who is a house wife, apparently asymptomatic 13 yrs ago and then she noticed mass per anum with bleeding , went to hospital and diagnosed as haemorrhoids and got operated.

- Since 3 yrs she has history of muscle aches, for which she is using NSAIDs.

- She has h/o fever 20 days back, got treated in the local hospital, and 

- Since 20 days she has generalized weakness.

- She also has h/o vomitings since 3 days, with food as content, non - projectile , non bilious.

Apprisal

History was taken well.

Good lab work clear evaluation was done 

Negative points

There are no clinical pics of the symptoms like pedal edema.

Proper chronological order of symptoms apperance was not done 

Fever chart was not included.

No IO charting was done though it was told it should be strictly monitoredit would have been better if urine was sent for eosinophils for interatial disease

My Analysis

This is  case of CKD ?

 Chronic interstitial nephritis secondary to plasma cell dyscariasis, (multiple myeloma - 70% plasmacytosis).

Patient with coma and renal failure 

https://ananyapulikandala106.blogspot.com/2021/06/a-35yr-old-female-elog.html

Overview

A 35 yr old female with Fever and Diarrhea since 5 days( 4 to 5 times a day with blood discharge).

Back pain( 5 days ago) with abdominal pain and chest pain.

Apprisal

Very well presented 

With good fever charting with all the necessary information.

History was taken detailed way 

Follow up was good 

All the tests were properly done 

Negative

I could not find the negative data in the elog 

My analysis

It could be the hypoxia which could have caused the permanent brain damage which was the reason for her vegetative state . Subjectively she was told better but objectively no improvement was Seen. Hospitalisation has increased the infection to the bed sore it would have been better if discharged early as it was permanent damage and was impossible to treat anyway.

Q4: Testing scholarship competency of the examinees ( ability to read comprehend, analyze, reflect upon and discuss captured patient centered data as in their 'original' answers to the assignment for May 2021):

Please analyze the above linked patient data by first preparing a problem list for each patient (based on the shared data) and then discuss the diagnostic and therapeutic uncertainty around solving those problems. Also 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. 

Analysis the data

 https://ananyapulikandala106.blogspot.com/2021/06/a-35yr-old-female-elog.html 

Analysis of  A 35 yr old female with Fever and Diarrhea since 5 days( 4 to 5 times a day with blood discharge).

Back pain( 5 days ago) with abdominal pain and chest pain

Vegetative state of the patient could be due to  hypoxia which could have caused the permanent brain damage which was the reason for her vegetative state . Subjectively she was told better but objectively no improvement was Seen.

https://pubmed.ncbi.nlm.nih.gov/19362767/

Link supporting the data 

Intermittent Fever spikes can be explained due to the bed sores clearly explained through culture of the sores 

Sepsis might be the reason for encephalopathy by altering the blood brain barrier 

https://www.hindawi.com/journals/amed/2014/762320/

Q 5) Testing scholarship competency in  

logging reflective observations on your concrete experiences of this last month : (10 marks) 

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

The telemedical learning from the hospital has been a new experience and we  learnt quite lot of things through reflective observation during lockdown.  it's a bit challenging as we have just entered internship ,We have learnt elogging of the cases in a very short span of time and made juniors do so. I could answer the questions from juniors easily as I have been part of many discussion in ICU and wards . By doing this assignment I could view many cases and many case scenarios through which I learned many things

JUNE ASSESSMENT

July 28, 2021

JUNE ASSESSMENT

 Question 1: Competency tested for Peer to peer review and assessment : 

Please go through one particular answer of ten students in this link:

https://generalmedicinedepartment.blogspot.com/2021/06/bimonthly-formative-and-summative_19.html?m=1

and share your peer review of each answer with your quantitative marking input as well as qualitative insights into what was good or bad about the answer. 

 1. PULMONOLOGY

https://soumyanadella128eloggm.blogspot.com/2021/05/a-55-year-old-female-with-shortness-of.html

1) Evolution of symptamatology

20yrs ago- 1st attack of shortness of breath

From then, every year in January, episode lasts for a week

12yrs ago- admitted to hospital with severe shortness of breath

Current episode:

Started 30 days back, dyspnoea on exertion, relieved on rest, 

But since 2 days, dyspnoea even at rest

Possible explanation: attacks of dyspnoea can be triggered by winter season, vegetative matter, dust, pollen ( provided dyspnoea occurred at the time of working in rice fields) 

Possible etiology: vegetative dust (RICE) 

On investigation: upon CT, lower airway problem is seen

Other associated symptoms :

   1. Pedal edema since 15 days up till ankle level

   2. Facial puffiness since 15 days

MY OPINION AND ANALYSIS:-chief complaints:-

Being SOB,facial puffiness and pedal edema

TO RULE OUT CARDIAC CAUSE OR RENAL CAUSE

As investigations and clinical examination show

BRONCHIECTASIS

AND ACUTE EXACERBATION OF COPD..

Im convinced with her analysis and review

Question 2-4: 

Patient centered data 

captured by students from 2016 batch in the link below:

MULTISYSTEM:

https://nikithaedam48.blogspot.com/2021/06/18-year-old-malefrom-miryalagudawho-is.html?m=1

CNS :

https://pallavi191.blogspot.com/2021/06/gm-cases.html?m=1

Renal :

https://61tejarshini.blogspot.com/2021/06/general-medicine-case-discussion.html?m=1

Captured by one student from 2017 batch in the link below :

CVS :

https://60shirisha.blogspot.com/2021/06/medicine-case-discussion_14.html?m=1

Captured by one student from 2019 batch in the link below :

Abdominal : 

https://casescape.blogspot.com/2021/06/acute-kidney-injury-secondary-to.html?m=1

MY ANALYSIS OF THE FOLLOWING CASES:-

1.https://casescape.blogspot.com/2021/06/acute-kidney-injury-secondary-to.html?m=1

Overview:-

pt is diagnosed with AKI SECONDARY TO UROSPESIS

IN 2019

Came with similar complaints in june 2021

Could probably be a case of AKI ON CKD

RATHER THAN AKI 

APPRAISAL:-GOOD CHARTING OF TRENDS OF SERUM CREATININE AND TLC COUNTS

NEGATIVE POINTS:-

COULD HAVE SHARED DEINDENTIFIED IMAGES OF THE PATIENT SO AS TO GIVE A CLEAR AND DETAILED OPINION ABOUT EXAMINATION 

COULD HAVE SHARED A MORE DETAILED HISTORY OF HER HISTORY AFTER DIALYSIS SESSIONS FROM 2019 to 2021 

FEVER CHART SHOULD HAVE BEEN SHARED

ANALYSIS:-THIS COULD BE AKI ON CKD

RATHER THAN AKI ALONE

2. CNS :

https://pallavi191.blogspot.com/2021/06/gm-cases.html?m=1

OVERVIEW:-

chief complaints of sudden fall followed by weakness of both the lower limbs (paraplegia) and loss of hand grip 10 days back, associated with bowel and bladder incontinence.

He is a known case of TB since 1month and on ATT - HRZE

Probably could be pott’s spine secondary to TB

APPRAISAL:-

Well

Presented case with detailed info about patient and imaging reports

NEGATIVES:-

Fever chart should have been shared and SOAP format of patients everyday progress

ANALYSIS:-Quadreparesis secondary to infectious spondylitis of C4, C5, C6, C7 and D1 with Epidural abscess at C5 - C6 level.

Clinically CNS:

Speech - normal

No signs of meningeal irritation

                  Right.        Left

Tone. UL.  N.              N

           LL  increased. Increased

Power UL.  4/5.         4/5

             LL.  1/5.          1/5

Cranial.nerves.  : Intact

Sensory system : normal

Reflexes:

            Right.         Left

Biceps. 3+.             3+

Triceps. 3+.            3+

Supinator. 2+.         2+

Knee.          3+.         3+

Ankle.        3+.          3+

Plantar: extensor

I dont these findings actually are supportive of the daignosis

Because in a case of quadriparesis

The examination findings donot correspond

3. Renal :

https://61tejarshini.blogspot.com/2021/06/general-medicine-case-discussion.html?m=1

OVERVIEW:-Complaint of Altered Sensorium (Hypo active):It's since  Morning,lethargy.

History of fever 10 days back,lasted for 3 days,(Outside Creatinine ?11-14.8)

Followed by Pedal edema with Anasarca with Shortness of breath present even at rest .

(Outside Creatinine reports 11)

He is a known case HYPERTENSION:5 YEARS and on T.STAMLOBETA OD.

He is also a known case of CHRONIC KIDNEY DISEASE:5 YEARS and on Conservative Treatment

(Outside Creatinine =? 3.2 mg/dl,5years back).

Present creatinine of 20mg/dl and previous baseline creatinine above normal 

It is a case of AKI ON CKD with Level of consciousness:Drowsy but Arousable (Hypoactive, delayed response to commands).

Signs of meningeal irritation:No neck stiffness,no kerning's sign.

Higher mental functions: Intact

Reflexes: Present.

Suggestive of UREMIC ENCEPHALOPATHY (since urea levels being 340mg/dl)

NEGATIVES:-could have shared more clinical

Images (deidentified)

And fever chart should have been shared

Recent trends of RFT could have been shared

APPRAISAL:-Good presentation of the case with proper history and treatment plan

ANALYSIS:-

Since baseline creatinine levels are above normal

And current compliants of anasarca

With raised creatinine of 20mg/dl and urea of 340mg/dl

With a drowsy state suggests AKI ON CKD WITH UREMIC ENCEPHALOPATHY

4. CVS :

https://60shirisha.blogspot.com/2021/06/medicine-case-discussion_14.html?m=1

OVERVIEW:-A 70 year old with complaints of Distension of abdomen and shortness of breath Grade-3 since 5days with ECG  Showing Atrial fibrillation

And 2D Echo ;

Akinetic segment in LAD territory with EF 35%  and RVSP 100mmhg

B/L pleural effusion,mild pericardial effusion.

Diagnosed as

HFrEF with Atrial fibrillation 2 to ?IHD

Her biochemical report showing severe hyperthyroidism possibly relating to her refractory Atrial fibrillation 

APPRAISAL:-well

Presented case with history and detailed findings in ECG and 2D ECHO

NEGATIVES:-Could have shared the BP CHARTING AND FEVER CHARTING with deidentified clinical

Images of patient.

ANALYSIS:-A 70 year old with complaints of Distension of abdomen and shortness of breath Grade-3 since 5days with ECG  Showing Atrial fibrillation investigations showing

HFrEF with Atrial fibrillation 2 to ?IHD

And Her biochemical report showing severe hyperthyroidism possibly relating to her refractory Atrial fibrillation 

Q2) Share the link to your own case report 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. 

http://arunrollno46.blogspot.com/2021/07/aki.html

Q 5) Testing scholarship competency in  

logging reflective observations on your concrete experiences of this last month : (10 marks) 

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

THIS POSTING HAS BEEN A LEARNING EXPERIENCE ON ANALYSING THE LOGGING THE PATIENT DATA AND GETTING TO DISCUSS THE CASE WITH MY COLLEAGUES AND PGS AND THE FACULTY AND I HAVE LEARNED ABOUT THE VARIOUS TREATMENT PROTOCOLS AND HANDS ON EXPOSURE REGARDING SAMPLE COLLECTION, ABG, RYLES TUBE AND FOLEYS CATHETER INSERTION, ASCITIC TAP, PERFORMING DIALYSIS SESSIONS , PERFORMING CPR, OBSERVING INTUBATION, CENTRAL VENOUS CATHETERIZATION AND PRESENTING THE CASES IN 2-4 sessions.

heart failure

A 60-year-old male patient resident of bhongiri came to the OPD with chief complaints of shortness of breath (grade3-4 according to NYHA classification )since yesterday ;complains of abdominal distension since yesterday ,decreased urine output since yesterday , B/l  Pedal edema since   Yesterday and  burning micturition since two days .

History of presenting illness: –

Patient was apparently a symptomatic till yesterday then he developed shortness of breath (grade3-grade4) according to NYHA with Orthopnoea not associated with PND , Palpitations chest pain.

Complains of abdominal distension not associated with nausea or vomiting.

Complains of bilateral Pedal edema of pitting type up to the knee.

Complains of decreased urine output since yesterday complains of burning micturition.

Known case of alcohol Consumption – occasionally(once a week- 90ml whiskey)

k/c/o htn on irregular medication

Not a known case of diabetes mellitus 

past history:- 

he was admitted in july 2020 with similar complaints and was diagnosed with acute decompensated heart failure with moderate MR.

He stopped his medications since 3 months.

Personal history: –

Marital status-married

Appetite – normal 

Diet-mixed

Bubble and bladder – regular

Addictions – alcohol consumer occasionally, stopped since one year.

No Known allergies.

Family history: –

Insignificant

General physical examination –

Patient is conscious coherent and cooperative and examine well lit room.

Pedal edema : ++

No signs of pallor, Cyanosis, clubbing, Icterus, lymphadenopathy .

Temperature : 98.5° F

Pulse rate: 94 BPM

Respiratory rate: 18 cycles per minute

BP: 120/ 70 mm of Hg

Spo2: 96%

Grbs : 115mg%

CVS:-S1, S2 heard ; Pan systolic murmur heard in mitral area.

apex beat: left 5th ics

elevated jvp

orthopnea:+

no thrill

pulse: rate:94bpm

            rhythm: regularly irregular

Respiratory system: –

Dyspnea: present (grade3-4)

Position of trachea – Central

breath sounds – BAE plus

Crepitations heard in lt. MSA, IAA

Per Abdomen: –

Shape of the abdomen – obese

Tenderness – absent

No palpable mass , no organomegaly

Hernia notifies intact, no free fluid ,no bruits.

bowel sounds : present

Central nervous system examination –:

Level of consciousness – alert

Speech-normal

No signs of Meningeal 

Reflexes normal.

 

ecg findings:. inverted p waves in lead 1 ,2 ,3 and ventricular premature complexes seen in V4, V5, V6.

junctional rhythm with occasional vpc.

Provisional diagnosis:- acute decompensated heart failure

prostatic adenocarcinoma

A 70 yr old male came to hospital with cheif compliants of severe burning micturition and fever since 1 month

History of present illness:-

Patient was apparantly asymptomatic 6 months ago then developed burning micturition with decreased urine output which worsened since one month. The pt also developed fever since one month which is of high grade, insidious in onset and relieved upon taking dolo-650. He had pedal edema one month ago ,which is  bilateral, of pitting type upto the ankles which got relieved when he used medication. He also developed loss of appetite since one month and has significant weight loss.

Drug history

He is using paracetamol regularly for his fever, since 1 month.

Past history:-He is not a c/o Diabetes mellitus, Hypertension ,asthma, TB, Epilepsy

Personal history:-

Diet: Mixed

Appetite: decreased since 1 month

Bowel and bladder: Regular 

Micturition: decreased urine output(usg showed BPH)

Allergies: drinks toddy (rarely)

Family history:

No history of Diabetes mellitus,Hypertension,heart disease or stroke,tuberculosis,cancer

General examination

patient was consious,coherent and cooperative and examined in a well lit room.

VITALS:

Pulse rate: 98 bpm

Respiratory rate: 18/min

BP: 130/80 mmHg

Temperature: 98.4F

GRBS: 131mg%

SPO2: 98% at room air

            

Pallor: absent

Icterus: absent

Clubbing: absent

Cyanosis: absent

Lymphadenopathy : enlarged lymph nodes in the left anterior side of the neck(matted)

Edema of feet: present, upto ankle, pitting type.

Malnutrition :present

Dehydration :mild

Systemic examination

CVS

• S1 and S2 heard
• No thrills
• No murmurs

Respiratory System

• Vesicular breath sounds heard
• Trachea is in central position
• No wheezing
• No Dyspnoea

Abdomen

• Scaphoid shaped abdomen
• No tenderness
• No palpable mass, no organomegaly
• Bowel sounds are heard

CNS

• Conscious and normal speech
• Normal gait
• Cranial nerves normal
• sensory system normal
• Motor system normal
• No signs of meningeal irritation.

INVESTIGATIONS:

CBP

HEMOGRAM

CUE

Blood parasite:-

Culture:

1. Urine

ULTRA SOUND

FNAC of the lymphnode in the neck:-

Slides:

PROVISIONAL DIAGNOSIS

Obstructive uropathy ?AKI

Post renal Benign prostate hyperplasia

? adenocarcinoma

TREATMENT 

Fluid correction <2l/day

salt restriction with <2g/day

 ivf 1๏ ns @30ml/HR

Inj.Lassix 40mg iv/bd

IO CHARTING

TAB.Ondansetron MD/PO/TID

TAB.Nodosis 500mg/PO/BD

Inj.Meropenem 500mg/IV/BD

Altered sensorium under evaluation with DKA

A 47 year old woman, a resident of  Nalgonda district , a housemaker was brought to the casualty yesterday with the chief complaints of 

Altered sensorium since 4 am yesterday morning , the patients son tells that she has been in an altered state with no vocal response since 4am yesterday.

HOPI:

Patient was apparantly alright and then developed symptoms suggestive of COVID-19  on 4/06/2021 and she was tested positive after which she received LMWH, PIPTAZ , METHYPRED for 5 days. She was diagnosed with DM 25 days ago and her blood sugars were high  on admission (600mg/dl) and she was started on human mixtard insulin according to sliding scale since then.

Past history:

Not a known case of htn, cva , cad, tb , bronchial asthma.

Personal history:

married

Diet : mixed

Appetite: normal

Bowel and bladder: regular

Sleep: adequate

No known allergies and no addictions.

Famliy history: not significant

General physical examination: 

Temp: afebrile

PR:79bpm

RR:20cpm

On presentation to us, 

Her GCS was 

E2V2M4 

Her GRBS was 390mg/dl

BP was 140/80

Her  pupils were reacting to light bilaterally 

Her right pupil was dilated

There were no meningeal signs

All her upper limb reflexes were exaggerated 

Her lower limb reflexes were absent and plantars were mute

Cvs - S1,S2 +

Lungs - BAE +

 INVESTIGATIONS: 

HAEMOGRAM:

CUE

Urine for ketone bodies

LFT

ABG 

Grbs charting

ECG

MRI 

Treatment:

- head end elavation

-O2 supplementation, maintain Spo2-92%

-ryles tube feeding

-IVF: 2 pint NS @75ml/hr with 1 amp Optineuron

-inj. Monocef 1gm/iv/bd

-inj.pantop 40mg/iv/od

-inj. Human actrapid insulin @3ml/hr and taper according to algorithm

-tab. Dolo 650mg  po sos

-inj. Neomol100ml iv if temp is >102°F

-inj. Mannitol 100ml/iv/tid

-inj. Acyclovir 800mg/iv/tid

-grbs charting  hourly

-monitor vitals and temperature

marchiafava bignami syndrome

Sunday, June 6, 2021

A 38 year old male with chief complaints of forgetfulness and irrelevant talking.

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent.Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs". This E log book also reflects my patient-centred online learning portfolio and your valuable comments on comment box is welcome. 

Name : D Arun Kumar

Roll. No. 046

Intern

Case history :

A 38 year old male patient, presented to the OPD with the chief complaints of  

1. forgetfulness since 3 months,  

2. irrelevant talk since 3 months, and 

3.gait disturbances since 2 months.

History of presenting illness :

Patient was apparently asymptomatic 3 years back when he developed pain abdomen and was admitted to various hospitals and was diagnosed with acute pancreatitis.

He was diagnosed with type 2 diabetes mellitus, (secondary to acute pancreatitis) 3 years back. Since lockdown, he has been consuming more than 1litre of whiskey per day. 

 3 months back he consumed only  alcohol without any food for one week, and One day morning, the attenders were unable to wake him up from sleep. He was taken to Mamatha medical College where he was diagnosed with alcoholic ketosis and was on treatment for 2 weeks . Since then , he has not been able to talk, he has not been able to respond to command. He has been unable to remember things and has not been able to do things by himself.

Past history:

 patient is a known case of type 2 diabetes mellitus since 3 years and was on medication. 

Personal history:

Married

Appetite:  normal 

Diet:  mixed 

Bowel and bladder habits :  regular

Sleep:  adequate

Addictions :   alcoholic since 8years , used to consume 1litre of whiskey per day; 

smoked 2-4 cigarettes daily since 1 year. 

Family history: not significant.

General examination: 

The examination was done after obtaining informed consent in a well lit room.

The patient was conscious, well oriented to persons, Not oriented to place and time. 

There was no pallor, icterus, clubbing, cyanosis, lymphadenopathy, and edema. 

Vitals :

Temperature : afebrile

Pulse rate : 70bpm

Respiratory rate : 20 cps

Blood pressure : 110/70 mmHg

SpO2 : 99% at room temperature. 

GRBS : 269 mg/dl

Cvs: 

S1, S2 heard 

Respiratory system: Bilateral air entry is present. 

Abdomen: 

Soft, No tenderness, no palpable mass. 

Central nervous system :

  Conscious, not oriented to time , place and person 

Speech: no response.

No signs of meningeal irritation ( no neck stiffness, kerning's sign negetive)

Pupils - NRSL

Rombergs sign - negetive

   

                                         Right.                    Left 

Tone- UL.                            N                          N

           LL.                            N                          N

Power- UL                         5/5                       5/5

              LL.                        5/5.                      5/5

Reflexes.        

             B.                             +2.                          2+

             T.                              +2.                          2+

             S.                              +2.                          2+

             K.                                -   Not    elicited   -

             A.                               +.                             +

             P.                       decreased.          decreased

Lobar function:

Frontal lobe : unable to perform problem solving, lack of insight.

Parietal lobe : able to perform series of motor activities.

Right and left orientation ---->positive

Finger recognition ---->positive

Visuo-spatial orientation ----> negetiv

Occipital lobe : able to recognise familiar faces. 

Investigations:

Hemogram-   

Normocytic normochromic 

Urine examination-

RFT -

UREA.                 :  14mg/dl

CREATININE.     :  0.8 mg/dl

PHOSPHORUS  :  4.6 mg/dl

SODIUM            :  138 mEq/L

POTASSIUM     :  4.6 mEq/L

CHLORIDE        :  99 mEq/L

LFT- 

AST : 16 IU/L

ALT : 10 IU/L

ALP : 180 IU/L

TOTAL PROTEINS : 6.5 mg/dl

ALBUMIN : 3.77 mg/dl

A/G RATIO : 1.38 

ECG-

Vent rate : 60BPM

PR interval : 138ms

QRS duration : 74ms

QT/QTc : 419/419ms

Avg RR : 996ms

P-R-T axes : 12  23  34

MRI

Mild diffusely thinned out Corpus callosum.

Normal grey/white matter differentiation

Nasal ganglia and thalami are normal

Cranio-vertebral and Cervico-medullary junctions are normal.

Sella, pituitary and parasellar regions are normal. 

Pituitary gland, pituitary stalk, and hypothalamus are normal. 

Provisional diagnosis:

Alcohol induced dementia 

K/c/o type 1 diabetes mellitus

K/c/o alcohol dependence syndrome. 

Treatment:

Inj. Thiamine 2amp in 100ml NS /IV/ TID

Inj. Human Mixtard S/C -- 

Tab. Haloperidol 165mg PO/OD

Tab. Pregabalin 75mg PO/MS 

Tab. Divalproate 100mg 

Tab. Memantine 10 mg 

Tab. Sprolit plus 1/2 tab OD

short case

Consolidated left apical region of lung -by- 1601006051

D. ARUN KUMAR

HALL TICKET NUMBER - 1601006051

This is an E log book to discuss our patient de- identified health data shared after taking his/her consent 

A 51 year old male patient resident of Miryalguda , farmer by occupation ,presented with a chief complaint of  

1. Fever  since 10 days 

2. Cough  with sputum since 10 days 

3. Shortness of breath since 7 days 

History of present illness

Patient was apparently asymptomatic 10 days back then developed following symptoms 

Fever which was insidious in onset and it was associated with chills and rigors with diurnal variation which was more during the night and was relieved on medication 

He then developed Expectorate Cough which  gradually progressed more during the nights followed a similar  diurnal pattern . It aggrevated  during exposure to colder climates .The sputum was scanty and yellow which was non foul smelling

Cough was associated with Chest pain  which was non radiating in nature and aggrevated on lying down relieved on sitting upright 

He later developed gradually Dyspnea which went on to interfere his daily activities (indicating MMRC Grade 3 / 4 ) and eventually progressed  to orthopnea 

No history of wheeze 

Past history 

No history of 

Asthma 

Diabetes Mellitus 

TB

Hypertension 

Epilepsy 

COPD : 6 yrs  recurrent attacks of exacerbation twice a year are seen

Family history

No relevant  family history

Personal history 

Sleep: disturbed due to SOB

Bowel and bladder regular

Appetite: normal

Diet: Mixed

No food or drug allergies 

Addictions : smoking  since 40 yrs ( 3 to 4  cigarettes a day )

      Smoking index 120 

      Alcohol  since 40 yrs  

Examination 

 Patient was conscious coherent and cooperative 

Seems to be undernourished 

Vitals 

Pulse

•  82 bpm
• Regular
• Normal volume 

Bp 100/70 mm hg

Respiratory rate 29 cpm 

On physical examination 

Pallor absent

Icterus absent 

Cynosis absent 

Clubbing absent 

Lymphadenopathy absent 

Edema absent 

Systemic examination 

Respiratory 

Upper respiratory tract examination 

• Nostrils : Normal
• Nasal septum: No deviated nasal septum
• Nasal polyps: No nasal polyps
• Tonsils :No enlarged tonsils
• Posterior pharyngeal wall appears to be normal

Inspection 

• Shape and symmetry :Elliptical and symmetrical 
• Spine: central
• Trachea :Appears to be central

Respiratory movements   decreased on both sides

Breathing pattern was Thoracoabdominal

No visible pulsations 

No visible scars or sinuses

Palpation

Spine is central

Trachea  is central

Dimensions 

                    AP 16.5

                    Transverse 23.5 

Chest expansion was equal on both the sides

Vocal fremitus was increased on left infra clavicular and mammary region

Apex beat was felt on 5 th intercostal space medial to MCL

Percussion 

On purcussion dull note was heard on 

• Left infra clavicular
• Left  mammary 
• Left infra scapular

Auscultation

Tubular breath sounds 

There was an Increased  vocal resonance on left infra clavicular and mammary ( bronchophony and whispering pectoriloquy)

Crepitation were felt on left infra axillary region

Cvs 

Normal S1 S2 heard 

No murmurs

Apex beat felt on 5 th intercoastal space 

CNS

No focal deficits seen

Investigations

 

Chest x-ray:

Diagnosis 

 ? fibrosis in the left apical region 

TREATMENT

-First line- broncho dilators short acting -salbutamol nebulization

-Steroids

-Anticholinergic inhalers include tiotropium (Spiriva), ipratropium.