General medicine bimonthly assignment August
36 Tejaswi enduri
E-LOGS GENERAL MEDICINE
BIMONTHLY ASSESSMENT-AUGUST -2021
This blog is an assessment for questions linked below :
ANSWER 1 :
*Critical appraisal of the captured data and peer review
REVIEW FOR ANSWERED QUESTION IN :
LONG CASE :
A 47 year male patient resident of Nalgonda came with chief complaints of
abdominal distension and swelling of bilateral lower limbs since 6 months which is gradually increasing since 10 days and and fever since 2 days.
- evolution of symptomatology is well described
- Proper past ,personal ,family ,surgical ,medical and immunization histories are provided.
- Differential diagnosis for the conditions is properly mentioned
- All the necessary pictures are provided with
- A very well Detalied examination of the abominal system is done .
- further plan of treatment is given clearly.
Decompensated cheronic liver disease secondary to ethanol consumption, with ascites, portal hypertension, hepatic encephalopathy stage 1 and spontaneous bacterial peritonitis.
SHORT CASE :
A 43year old female came to opd with chief complaints of:
CHEST PAIN SINCE 10 DAYS
FEVER SINCE 10 DAYS
COUGH WITH EXPECTORATION SINCE 10 DAYS
- the history taking and examination is done thouroghly
-a detailed account of examination of respiratory system is given
- investagions were very clear
- symptomology is also well explained in an elobrated way
Type 1 Respiratory Failure due to Pleural Effusion/Empyema likely due to a bacterial infection.
SHORT CASE-2:
A 18yr old male presented with complaints of difficulty in walking since 1 month
Bilateral lower limbs weakness since 15 days
- a thorough history is taken and case is well presented
- necessary images are inserted for better understanding
- also the diagnosis well explained
- But no treatment mentioned
Bilaterally Symmetrical Ascending Proximal > Distal LMN Type Quadriparesis due to Peripheral Neuropathy upto level C7 likely due to Guillian Barre Syndrome (Acute Inflammatory Demyelinating Polyneuropathy)
ANSWER 2 :
Problem list for each patient and the diagnostic and therapeutic uncertainty around solving those problems as follows:-
LONG CASE
Problem list
Abdominal distension which is insidious in onset and gradually progressive in nature
subsequently noticed bilateral swelling of lower limbs
increased urine output
The past 10 days he noticed abdominal distension associated associated with swelling of bilateral lower limbs which started at ankle and progressed upto knee
fever high grade, intermittent in nature not associated with chills, since 2 days
Anorexia, fatigue and generalized weakness since 3 months,,
disturbed sleep since one month,
Excessive day time sleepiness and night distured sleep
Yellowish discoloration of eyes 3 months back now it subsided
Provisional diagnosis -
Decompensated chronic liver disease
Etiology - chronic ethanol related.
Ascites , SBP, Hepatic encephalopathy
? Hepatorenal syndrome. Esophageal gastric ligation bands were.
Child-Pugh SCORE - C
Treatment given -
1.Tab PAN 40 MG OD
2. TAB . RIFAGUT 550 mg po BD.
3. SYP.HEPAMERZ 10 ml Bd
4. SYP. Lactulose 10 ml H/ S
5.5. Tab udiliv 300 mg po BD.
6. Inj . Ciprofloxacin 500mg iv Bd
7. Daily abdominal girth .
8. Salt restricted diet.
Short case 1
Problem list
CHEST PAIN SINCE 10 DAYS
FEVER SINCE 10 DAYS
COUGH WITH EXPECTORATION SINCE 10 DAYS
Pain in the right SIDE OF THE CHEST region , non radiating
pain increased with inspiration and coughing .
complaints of fever, moderate to high grade ,associated with chills and rigors , since 10 days
cough with scanty mucoid expectorant which wasn't blood tinged, non foul smelling since the past 10 days
Provisional Diagnosis:
Right sided pleural effusion
Final diagnosis:
Type 1 Respiratory Failure due to Pleural Effusion/Empyema likely due to a bacterial infection.
Treatment:
1. IV fluids
2. Inj Augmentin 1.2g/IV/BD
3. Inj Pantop 40mg/ IV/OD
4. Tab dolo 650mg/PO/SOS
5. Syrup Ascoril / PO/
Short case 2
18 year old boy came to the OPD due to weaknes ,and inability to walk which spread to hands as well .
Problem list
complaints of difficulty in walking since 1 month
Bilateral lower limbs weakness since 15 days
difficulty in wearing and holding footwear
It gradually ascended to involve his calf muscles,
difficulty in walking, which required support (walls).
difficulty in getting up from bed,
Difficulty in standing from a sitting position. difficulty in squatting.
difficulty in climbing stairs
weakness in his hands
difficulty in holding glasses, buttoning and unbuttoning of his shirt and writing
difficulty in mixing his food but no difficulty in taking the food to his mouth.
History of buckling of knees +
Diagnosis
Patient was diagnosed with LMN type quadripares due to periperal neuropathy ( might be gullian baree syndrome )
Answer 3
Long case
Review of literature around sensitivity and specificity of the diagnostic interventions mentioned and efficacy of the therapeutic interventions mentioned for each patient.
Investigations done are
CBP -
HB - 10.7
TLC - 19100,
PLT - 1.50 LAKH
N - 90
CUE -
Albumin- 2+
Sugar- nil
Rbcs- nil
Pus cells - 4-5
RFT -
Blood urea - 116 mg/ dl
Serum creatinine - 4.8 mg/dl
Sodium - 128 meq/l
Potassium - 5.5meq/l
Chloride - 102 meq/l
Uric acid - 5.0
Calcium - 9.1
Phosphorus - 8.0
LFT -
Total bilirubin - 1.63 mg/ dl
Direct bilirubin - 0.40mg/dl
SGOT - 34 IU/L
SGPT - 20 IU/L
ALP - 186 IU/L
Total protein - 5.4 gm/dl
Albumin - 2.06 gm/ dl
RBS- 70mg/dl
Ascitic fluid analysis -
SAAG - 1.74. Serum albumin - 2.01
Ascitic albumin - 0.36
Ascitic LDH - 120 IU/ L
Ascitic sugar - 52 mg/ dl
Ascitic protein - 0.8 g/dl
Appearance - Clear
Neutrophil count - 405.
Total count - 675
RBCS - Present.
PT - 16 Sec.
APTT - 32sec.
INR - 1.11
HIV - negative.
HbSAg -negative.
HCV - negative.
CUE -
RFT -
LFT -
Ascitic fluid analysis
ECG -
X ray - see any abnormalities in the abdomen ,it helps in arriving at a definite diagonis and helps in treatment .
Short case 1
INVESTIGATIONS
ECG: TO see the cardiac rhythm to check for abnormalities in the heart , to notice any arrythmias or any kind of heart diseases
Chest Xray PA view: To check for the morphology of the lungs pleura and the recesses , to see if there are any nodules
Or lesions or any abnormality
Haemogram:To get a detailed picture of the blood ,about the packed cel volume , RBC count WBC count platelets , to know the type of anemia
Smear :
Normocytic hypochromic with neutophelia and thrombocytosis
LFT: to know abt the liver function ,bilirubin levels and enzymes level
RFT: the fubction of the kideny is determined by this by knowing the creatinine and urea
USG ABDOMEM to diagnose any abnormality of the abdomen .
Pleural fluid analysis :
Pleural tap was done following all the aseptic measures, on right side 6 th posterior intercostal space, white viscous fluid was taken out and sent for analysis
CELL COUNTVolume: 1ml
Colour: pus like material
Appearance: Cloudy
Total Count: Plenty cells/cumm
DIFFERENTIAL COUNT
Neutrophils: 86%
Lymphocytes: 14%
RBC: Nil
Others: Nil
SUGARS: #34mg/dl
PROTEIN: #4.3gm/dl
Serum Protein: 6.9g/dl
Serum LDH: 319 IU/L
Cytology report:to get a detailed picture of the kind of cells and structure .
Smears showed rich cellularity composed of degenerating neutrophils only against eosinophilic proteniacious background
Impression: cytology suggestive of acute inflammatory condition
Short case 2
INVESTIGATIONS
HEMOGRAM
To know about the blood count ,the type of anemia ,the leucocyte count ,the idea of the smear .
smear -microcytic hypochromic anemia
serum electrolytes-
To check the level of electrocytes in the serum and asscess the reason
CHEST X-RAY- to ascess abnormlaitis in the chest
ECG:to assess the cardiac function and diagnose abnormalities .
ANSWER 4 :
ANSWER 5 :
Due to this pandemic, we are unable to appear directly and experience the patient but even though we had a very good experience which is not had been possible without the general medicine department. Dr. Rakesh Biswas sir, HOD made it possible by teaching every single aspect regarding capturing the patient-centered data.
We've got to learn a lot online too. As our college has created a group where we get all the cases taken up by interns and pgs and is being discussed and updated till the patient gets discharged. It feels accomplished .
It's great to have experience of taking the history of the patients admitting to our hospital in the 3rd semester itself and understanding why and how the disease is being caused.
These questions are making us curious to learn clinical subjects more efficiently.
We have learned how to take the history and data from a patient to communicate and diagnose the problem.
This paved a way for learning new things differently.
Sharing knowledge with our peers and interacting with them regarding the cases has been so helping full to us.
We have to learn the basic knowledge regarding how to interact with the patient and taking a history from them.
This has been a wonderful opportunity to interact with my peers.
The E logs which have been kept for us are helpful and made me learn so many new things.
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