135 U.AKANKSHA

         GENARAL MEDICINE: ASSIGNMENT

    QUESTION-1

    PULMONOLOGY CASE:

Evolution of symptoms were very well presented. Explanation for every treatment and causes were written in a very coherent manner.                                                    It would have been perfect if the cause for right heart failure was mentioned.                                                    Overall it was very well explained and easy to understand

https://aitharaveena.blogspot.com/2021/05/online-blended-medicine-assignment-may.html

NEUROLOGY CASE-1

The answers to the questions were written well but can be explained in a more detailed manner.                              It would have been better if the answers were written directly after the question, which would make it easier to understand the context.

https://02shishirareddy.blogspot.com/2021/05/assignment-45-year-old-female-patient.html

    NEUROLOGY CASE-2

The case was very well presented and explained.            All the keywords were highlighted which made it easier to get the concept and the mechanisms of treatment and the case were very well explained.                           The flowcharts definitely made an impact.

https://amishajaiswal03eloggm.blogspot.com/2021/05/medicine-blended-assignment.html

NEUROLOGY CASE -3

It could have been more elaborate.                                      If the topic of the case was mentioned it would have been easy to understand rather than using the link to learn about the case.                                                               It would have been much better if the main points have been highlighted. 

https://amitsharma1996.blogspot.com/2021/05/medicine-assignment-may-2021.html

 NEUROLOGY CASE-4

the explanation was good, but the certain points could have been highlighted.                                                           if a summary of patients details were given it would have been much easier to understand.

https://caseopinionsbyrollno05.blogspot.com/2021/05/medicine-blended-assignment-may-2021.html

   NEUROLOGY CASE-5

Very clean presentation and very well explained.                It was easy to understand.                                                      Can add some more details to the answers

https://.blogspot.com/2021/05/medicine-blended-assignment-may-2021.html

NEUROLOGY CASE-6

The summary of the patient was mentioned which made it easier to understand. The questions were explained in a very coherent manner. the presentation was neat, but certain points can be elaborated.

https://rishikoundinya.blogspot.com/2021/05/general-medicine-assignment-online.html

  NEUROLOGY CASE-7

The patients condition has neither been summarized nor the link to the case has been provided so it was impossible to understand the explanation despite being correct.

https://08arshewarpavankumar.blogspot.com/2021/05/a-40-year-old-male-with-complaints-of.html

  NEUROLOGY CASE-8

If the patients case has been summarized it would have been more understandable, but other than that the presentation was very neat and easy to understand. If main points were highlighter it would have been much better.

https://avulanikhil09.blogspot.com/2021/05/pulmonology_45.html

    CARDIOLOGY CASE-1

The cases should have been separated more clearly to avoid confusion. the explanation was good but should have organized information in amore coherent manner.

https://blendedasessmentmadhukumar.blogspot.com/2021/05/medicine-blended-assesment-may.html

QUESTION 2

A 28 year old male came with 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.

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

History of present illness:

Patient was apparently asymptomatic 1 month back, following which he developed productive cough, low grade fever for which he underwent sputum studies and tested positive for AFB bacilli and started ATT - HRZE regimen, 2 tab according to weight/PO/OD.

He developed generalized weakness and myalgia 15 days back.

10 days back, patient got up from bed and went to open the door and suddenly fell down, with no loss of consciousness and no froathing. Following which his brother got him up and since then Patient developed bowel and bladder incontinence.

No sensory impairment.

Past history:

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

Not a known case of DM,HTN, ASTHMA, EPILEPSY, THYROID DISORDERS, STROKE, CAD.

Personal history:

• Diet - mixed
• Appetite - normal
• Sleep - Adequate
• Bowel and bladder incontinence + since 1 week
• No allergies 
• No addictions

Family history:

    His father is a known case of TB and used ATT for 2 years

General examination:

•     Patient is conscious, coherent, co-operative and oriented to time, place and person
• 
  
•     No pallor, icterus, cyanosis, clubbing, koilonychia, lymphadenopathy and edema.
• 
  
•     Temperature - afebrile
•     PR - 80 BPM
•     RR - 16 cpm
•     BP - 100/70 mm Hg

Systemic examination:

• 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

CVS:

• S1, S2 heard
• No thrills
• No Murmurs

Respiratory system:

• Trachea - central
• BAE +
• NVBS heard
• No added 

Per abdomen:

Soft, non tender

Bowel sounds - heard

Hernial orifices - normal

No palpable masses

Provisional diagnosis:

Cervical myelopathy?

Potts spine?

Investigations:

Treatment given:

1. Inj. Optineuron 1Amp in 100ml NS  IV/OD

2. Inj. Thiamine 200mg in 100ml NS IV/TID

3. ATT - according to body weight 2 tab PO/OD

4. Bp/ PR/ Spo2/ Temp charting

Update:

FINAL DIAGNOSIS:   Quadriparesis secondary to infectious spondylitis of C4, C5, C6, C7 and D1 with Epidural abscess at C5 - C6 LEVEL

Links to the cases: 

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

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

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

 QUESTION 3:

MULTISYSTEM

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 deidentified and shared. Updates were logged in so that the case could be followed easily. No discussions on diagnostic and therapeutic uncertainties were given.

CNS:

The relevant medical history of the patient has been shared in a comprehensive and systematic manner. Advice at discharge was mentioned which provided an insight on what can be done. No diagnostic uncertainty was present. There were no discussions/links regarding the line of treatment followed.

RENAL:

All the required data has been included in the chronological order. All investigations (and their dates) were logged in. No leads, links or discussions were given. No diagnostic or therapeutic uncertainties were given.

CVS:

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 deidentified and shared. Links/leads/discussion regarding the diagnostic hallmark of the provisional diagnosis and therapeutic uncertainties were not mentioned.

ABDOMINAL:

The relevant medical history of the patient has been shared in a comprehensive and systematic manner. The reports of all the lab investigations conducted were deidentified and shared. No discussions on diagnostic and therapeutic uncertainties were given.

QUESTION 4: 

MULTISYSTEM:

Problem list: 

1. Gradual loss of weight
2. Polyuria, nocturia, polydypsia
3. Low backache
4. Vomiting
5. Loose stools
6. High grade, intermittent, fever
7. Yellow discolouration of eyes and urine 
8. Nausea & Loss of appetite
9. Burning micturition
10. DKA

Day 1 - IV fluids, Insulin, Vit K - Insulin is an accepted therapeutic drug for treatment of DKA.

Day 3 -  Syp Lactulose was given for constipation

Day 4 - Inj. Lorazepam was given as absence seizures were suspected. 

Day 5 - Cerebral malaria was suspected and Inj. FALCIGO, Inj. LEVIPIN, and Inj. DOXYCYCLINE was given.  

The provisional diagnosis is consistent with the symptoms and their progression. A peripheral blood smear can be done to confirm the diagnosis (Presence of Plasmodium falciparum in the smear will confirm it)

Other diagnosis that can be supported by the symptoms are

• Encephalitis
• Hepatic encephalopathy
• Acute Liver Failure

Treatment:

• FALCIGO - is an anti-malarial drug.
• LEVIPIL - is an anti-epileptic.
• DOXYCYCLINE - is an anti-malarial

The therapeutic interventions were specific and highly effective for the assumed diagnosis.

CNS:

Problem list:

1. Weakness of both lower limbs

2. Loss of hand grip

3. Bowel and bladder incontinence

4. Generalised weakness and myalgia

The diagnosis was Quadreparesis secondary to infectious spondylitis of C4, C5, C6, C7 and D1 with Epidural abscess at C5 - C6 level. This diagnosis was supported by an MRI of the brain with cervical spine. The specificity and sensitivity of MRI in diagnosing such an acute case of spondylitis was found to be very high, as compared to a CT scan.

Treatment given:

• Optineuron
• Thiamine
• ATT

RENAL:

Problem list:

1. Lower back and neck pain
2. Altered sensorium
3. Shortness of breath (grade 4)
4. Loss of appetite
5. Lethargy
6. Anasarca

Uraemic encephalopathy is a diagnosis of exclusion. Differential diagnosis include:

• Hypertensive encephalopathy - as the patient is a k/c/o hypertension, this is a probable diagnosis. 
• Metabolic encephalopathy 
• Fluid and electrolyte disturbances - serum electrolytes can be measured.
• Osmotic demyelination syndrome.

CVS:

Problem list:

1. Abdominal distension
2. Shortness of breath
3. Hypothyroidism

This was diagnosed as HFrEF with Atrial Fibrillation based on the ECG. ECG has very low specificity in diagnosing ECG. Left-ventricular ejection fraction is the diagnostic hallmark.

Treatment: 

Amiodarone is highly effective in treating arrythmia

Clexane is an anticoagulant. Since patients with AF have a higher risk of thromboembolism and stroke, anticoagulants are used to reduce the risk. Clexane is an effective and safe drug.

ABDOMINAL:

Problem list:

1. High grade fever
2. Bilateral pitting type pedal edema
3. Decreased urine output
4. Burning micturition

The diagnosis is consistent with the symptoms. The treatment given is appropriate. 

QUESTION-5

Reflective logging enable the student to stay up to date and keep a track of their progress . They enable one to apply their theoretical knowledge into practical application.In the times of COVID when we are unable to physically attend clinical posting and acquiring practical knowledge ,elogs enable us to keeping a track of the patient assigned and practice important skills like history taking .

Reflective logging give us an opportunity to know the patient and study the case, inspite of us not being in the hospital.