osce and learning points - prefinals

OSCE- PREFINALS

Case report:-

https://uakanksha.blogspot.com/2023/12/a-65-yr-old-female-with-syncope.html

Q.What is the best method to perform hba1c test with highest sensitivity?

The optimal cut-off for diagnosing diabetes in previously undiagnosed adults with HbA1c was estimated as 6.03% with pooled sensitivity of 73.9% and specificity of 87.2%. The optimal cut-off for Fasting Plasma Glucose was estimated as 104 milligram/dL with a sensitivity of 82.3% and specificity of 89.4%.

At present recommended threshold of 6.5%, HbA1c is more specific and less sensitive in diagnosing the newly detected diabetes in undiagnosed population from community settings.

https://dx.plos.org/10.1371/journal.pone.0242415

Q.What is insensible fluid loss? How does it effect of syncope.

Insensible fluid loss is the amount of body fluid lost daily that is not easily measured, from the respiratory system, skin, and water in the excreted stool. The exact amount is unmeasurable but is estimated to be between 40 to 800mL/day in the average adult without comorbidities. A total loss of approximately 600 to 800mL/day characterizes 30 to 50% of all water loss, contingent on the level of water consumed. Thus insensible water loss is a significant component of water balance and needs to be routinely monitored.

 Clues to hypovolemia include hydration of mucous membranes, skin turgor, resting heart rate, and intensity of peripheral pulses. Additionally, blood pressure particularly orthostatic changes and urinary output, are also important indicators of fluid status gleaned from a physical examination.

https://www.ncbi.nlm.nih.gov/books/NBK544219/

LEARNING POINTS:-

1.What is syncope and it's common causes.

2.clinical conditions which have centripetal obesity and muscle wasting.

3.What is insensible fluid loss and it's significant role in syncope.

4.best method to estimate hbA1c levels with highest sensitivity.

5.pedal edema and it's causes.

PREFINALS LONG CASE:-A 65 yr old female with syncope

CASE OF A 65 YEARS OLD FEMALE WITH SYNCOPE .

 This is an online e log book to discuss our patient's de-identified health data shared after taking his/her/guardians' signed informed consent. This Elog reflects my patient-centered online learning portfolio.

This is the case of a 65 years old lady ,housewife resident of Chinatunalgudam.

The patient presented to the casualty after an episode of loss of consciousness .

 Patient was apparently asymptomatic six days ago , when she had an episode of loss of consciousness  , associated with sweating , and after walking for a long time . 

Not associated with palpitation , flushing , chest pain , muscle weakness , slurring of speech, headache  . 

The patient was brought to the casualty and given medication and recovered completely  .

6 days ago - History of chest pain ( sudden onset , in the centre of chest , squeezing type , non progressive , not radiating ) with shortness of breath following exertion , which were both relieved on rest . 

She went to an RMP and was given an anti hypertensive agent .( which she consumed for the first time 3 days ago )

PAST HISTORY 

No similar complaints in the past 

She is a known case of hypertension since 3days 

Not a known case of diabetes mellitus , asthma , tb , cerebrovascular accidents , coronary artery disease .

No blood transfusions .

History of treatment for cellulitis of leg . 

FAMILY HISTORY 

3 siblings with DM

PERSONAL HISTORY 

Mixed diet , normal appetite 

Adequate sleep 

Normal bowel and bladder movements 

No allergies 

Addiction - sutta- 4 cigarettes/ day since 40 years 

Alcohol or toddy - 1 glass daily 

Daily routine 

Wake up - 7 am

8 am - breakfast (rice )and tea 

Afternoon (2:30pm)- lunch ( rice and curry ) 

Dinner - 9pm -rice and curry .

Sleep - 10 pm

GENERAL EXAMINATION 

The patient is conscious , coherent and cooperative 

Moderately built and moderately nourished 

There is absence of Pallor , icterus cyanosis,  koilonychia, lymphadenopathy . 

Pedal edema present 

VITALS 

BP- 120/80mmHg in sitting position with cuff in the right hand at the level of the heart 

PR- 67 bpm, normal rhythm , 

RR- 20cpm

Temp- Afebrile 

SYSTEMIC EXAMINATION 

CNS 

Higher Mental Functions 

Normal speech and language 

Normal memory 

No delusions or hallucinations 

Cranial nerve examination 

- I : Intact bilaterally 

III, IV, VI : Extraocular movements free and full bilaterally 

V : Intact bilaterally 

VII:Intact bilaterally 

VIII: No nystagmus, intact bilaterally 

IX,X : Intact bilaterally 

XII : Intact bilaterally 

MOTOR SYSTEM 

Bulk- normal  

Power : normal  power of 

- Shoulder , Elbow , Wrist , Smalll muscle of hand and hand grip bilaterally 

- knee , ankle  bilaterally 

Muscle tone :normal 

Reflexes -normal  : Biceps , triceps , knee jerk , ankle jerk bilaterally 

Cerebellar signs : Normal 

Sensory system examination 

Upper limb : Normal 

Lower limb 

- Crude touch , temperature , fine touch ,vibration sensation present bilaterally 

- Pain sensation is normal bilaterally  

CVS 

S1 S2 heard , no murmur 

No thrill 

Apical impulse felt 

RESPIRATORY 

Normal vesicular breath sounds in all areas 

No adventitious breath sounds

PER ABDOMEN 

Obese abdomen, umbilicus central and everted 

Soft , non tender 

No hepatomegaly no splenomegaly 

PROVISIONAL DIAGNOSIS 

?Syncope 

?Hypotension

INVESTIGATIONS 

A 43 year old male with SEIZURES

Saturday, July 8, 2023

43 YEAR OLD MALE WITH SEIZURES

Introduction: Welcome to my blog! I am U.AKANKSHA a 4th year medical student.This is an online E-log Entry Blog to discuss, understand and review the clinical scenarios and data analysis of patients so as to develop my clinical competency in comprehending clinical cases, and providing evidence-based inputs.It also reflects patient centered online learning portfolio.

Note: The cases have been shared after taking consent from the patient/guardian. All names and other identifiers have been removed to secure and respect the privacy of the patient and the family.

Consent: An informed consent has been taken from the patient in the presence of the family attenders and other witnesses as well and the document has been conserved securely for future references. 

A 43 year old male was brought to the casualty with comlains of involuntary movements of body since today morning. 

HISTORY OF PRESENTING ILLNESS: 

The Patient was apparently asymptomatic 4 days back when he had a binge of alcohol . he lost consciousness at his workplace and was taken to the hospital. At the hospital, the correction fluids were given and the patient was sent home. Today morning he had 2 episodes of involuntary movement of body (tonic movements with stiffening of body) lasting 1-2 minutes and relieved on itself. 

His wife checked his grbs at home after this episode and it was found to be 60mg/dl after which he was rushed to the hospital. In the hospital the correction was done inspite of which involuntary movements continued. He was then brought to our hospital. 

No uprolling of eyes or loss of consciousness during the episodes.

No c/o vomitings, headache, frothing from mouth, deviation of mouth, tongue bite, post ictal confusion, involuntary micturition/defecation.

PAST HISTORY:

No similar complains in the past.

K/C/O DM-II since 5 years on insulin. He was diagnosed with DM-II Incidently during an episode of fever for which he was initially prescribed OHA'S. The patient used to skip taking his medication. Due non compliance and very high sugars he was then shifted to insulin. 

N/k/c/o HTN, CVA, CAD, Bronchial asthma, thyroid disorders. 

DAILY ROUTINE :

The patient works as an attender in a college.

He lives with his wife and three children.

He doesn't always follow his routine and go to the college.

He gets up in the morning and freshens up and has breakfast. After his family leaves for work/college, he either goes to college or goes out with his friends and drinks alcohol. 

He often skips meals  as he forgets about them while he is drinking alcohol. He often consumes food late at night when he is very hungry. 

The alcohol consumption has increased in the last 1 year. 

On enquiring about the reason of chronic alcoholism with his family, they say that they can't think of any triggers as such. 

PERSONAL HISTORY

Diet: mixed 

Appetite: lost

Sleep: adequate 

Bowel: regular 

Micturition: normal 

Addictions: drinks alcohol since 20 years, chews gutka since 1 year 

Allergies: nil

Family history: not significant

GENERAL EXAMINATION

Patient is examined in a well lit room after taking an informed consent. 

Patient is conscious and coherent. 

No signs of pallor, icterus, clubbing, cyanosis, generalized lymphadenopathy, pedal edema 

VITAL AT THE TIME OF ADMISSION: (09/07/23) 

Temp: 98F

Pulse: 114bpm

RR: 20cpm

Bp:100/80 mm of hg 

Spo2: 99% at RA

Grbs: 

Systemic examination:

CNS EXAMINATION: 

GCS: 15/15

The patient is conscious. 

Speech: normal

Cranial nerves: intact 

Seonsory system: normal 

Motor system: 

                       UL                       LL

Tone R INCREASED       INCREASED

          L INCREASED       INCREASED

POWER

          R      5/5                        5/5

          L       5/5                        5/5

REFLEXES           R                       L

BICEPS               2+                      2+

TRICEPS             1+                      1+

SUPINATOR        0                         0

KNEE                    0                         0

ANKLE                  0                         0

PLANTAR             E                         E

RESPIRATORY SYSTEM EXAMINATION 

-Bilateral air entry is present, normal vesicular breath sounds heard. 

CARDIO VASCULAR SYSTEM

S1 and S2 are heard. No murmurs are heard

ABDOMINAL EXAMINATION:

Soft, non-tender. 

No organomegaly

Bowel sounds are heard. 

INVESTIGATIONS:-

USG ABDOMEN

X-RAY CHEST

EEG 

ECG

PROVISIONAL DIAGNOSIS: SEIZURES UNDER EVALUATION SECONDARY TO ? HYPOGLYCEMIA ? TOXIN MEDIATED

INVESTIGATIONS: 

9/07/23

SERUM ELECTROLYTES: 

Na: 145

K: 3.2*

Cl: 99

Ca2+: 1.13

Mg2+: 2

Blood urea 20mg/dl

S. Creatinine: 1 mg/dl

RBS: 130MG/DL

LFT:

total billirubin : 0.98mg/dL

Direct bilirubin: 0.20 mg/dL

AST: 45 IU/L

ALT: 30IU/L

ALP: 301* IU/L

Total proteins: 7 gm/dL

Albumin: 4 gm/dL

A/G ratio: 1.25

Hemogram:

Hb: 10.9gm/dL*

Total count: 6,400cell/mm3*

N/L/E/M/B: 75/18*/2/5/0

PCV: 34.6 vol%*

MCV: 78.6fl*

MCH: 24.8pg*

MCHC: 31.5%

RDW-CV:18.2%*

RBC COUNT: 4.40 millions/mm3*

PLATELET COUNT: 1.92lakhs/mm3

Smear

RBC: normocytic normochromic 

TREATMENT GIVEN: 

INJ. LORAZEPAM 2CC IV/STASTAT

INJ. LEVIPIL 1GM IN 100ML NS IV/STAT

INJ. SODIUM VALPROATE 300MG IN 100ML NS IV/BD

INJ. HAI S/C ACCORDING TO GRBS

INJ. THIAMINE 1AMP IN 100ML NS IV/BD

SYP. POTCLOR 15ml IN 1 GLASS OF WATER

10/7/23

FBS: 192 MG/DL

PLBS: 294 MG/DL

HBA1c: 6.5%

HEMOGRAM

Hb: 9.7gm/dL*

Total count: 7,800 cell/mm3*

N/L/E/M/B: 70/20*/4/6/0

PCV: 30.2 vol%*

MCV: 70.8FL*

MCH: 25.1pg*

MCHC: 32.1%

RDW-CV:18.2%*

RBC COUNT: 3.8millions/mm3*

PLATELET COUNT: 2lakhs/mm3

Smear

RBC: normocytic normochromic 

SERUM ELECTROLYTES: 

Na: 139

K: 3.5*

Cl: 101

Ca2+: 1.24

A 65 year old male with PAIN DISTENDED ABDOMEN and PAIN IN RT CHEST since 1 yr

65 year old male from beemanapally

Introduction: Welcome to my blog! I am U.AKANKSHA a 4th year medical student.This is an online E-log Entry Blog to discuss, understand and review the clinical scenarios and data analysis of patients so as to develop my clinical competency in comprehending clinical cases, and providing evidence-based inputs.It also reflects patient centered online learning portfolio.

Note: The cases have been shared after taking consent from the patient/guardian. All names and other identifiers have been removed to secure and respect the privacy of the patient and the family.

Consent: An informed consent has been taken from the patient in the presence of the family attenders and other witnesses as well and the document has been conserved securely for future references. 

Date of admission 21/7/23

65 yr old male agricultural labourer by occupation came to OPD with C/O abdominal pain, lower back pain radiating to b/l lower limbs, neck pain with stiffness since 1 year. 

History of present illness:

Patient was apparently asymptomatic 1 year ago later he developed pain in abdomen which

Insidious in onset gradually progressive. It is diffuse and dull causing discomfort.It is aggravated on eating,performing daily activities and walking.

Pain in the chest is lasts for 2-5 min which is sudden in onset.It is relieved by massaging that particular area.

Yesterday night patient complained of pricking type of headache due to dental carries on the right lower molars due to which he was unable to sleep. 

Past illness:

Diabetes since 15 years.

Not a K/C/O  HTN, TB, asthma, epilepsy or any other chronic illness.

TRAUMA :

4 years back, then he had a fall while taking his cattle to the field due to which the patient experienced severe pain in the right hip and was unable to walk. 

Right hemiarthroplasty was done immediately. 

Since 1 yr the patient gradually developed backache and dragging type of pain in b/l lower limbs.

 He had difficulty in bending, difficulty in getting up from sitting position, joint stiffness+.

Drug history 

Insulin injections twice daily

Personal history 

Diet mixed 

Sleep is adequate 

Appetite decreased

Bowel and Bladder: normal

No Allergies 

Addiction: alcohol occasionally once in few weeks

Daily routine

The patient wakes up at 5 am and gets ready.

He generally prefers to have roti and curries for his breakfast.

After that he sleeps for few hours.

His lunch items includes rice and vegetables, mostly around 1pm.

Then he goes outside for a walk in the evening and is back by 8pm for dinner.

Patient is an agricultural labourer but has left his job since he was diagnosed with diabetes that is 15 years back.

General examination

Patient is conscious, coherent and cooperative and well oriented to time place and person.

No pallor, icterus, cynosis, clubbing,edema, lymphedenopathy 

Vitals

Pulse rate-68 bpm

Blood pressure- 130/80mm Hg

Respiratory rate- 16cpm

CVS- S1S2 +, no murmurs

RS- BLAE +, NVBS heard

Investigations

Ultrasound 

ECG

2D ECHO

TREATMENT:-

Biphasic insulin 

Pantoprazole 40mg

Multivitamin tablets

GENERAL MEDICINE INTERNAL ASSESSMENT-1