GENERAL MEDICINE BIMONTHLY BLENDED ASSESSMENT (AUGUST)

 Question 1 :

Testing peer review competency in the active reader of this assignment :

Long Case :

Bilaterally Symmetric Chronic Progressive Inflammatory Peripheral Polyarthritis

This long case is very well presented.Patient past history and present history of illness was clearly taken and each and very particular was asked for diagnosing the patient condition.The differential diagnosis like Rheumatoid arthritis Psoriatic Arthritis,Enteropathic Arthritis,Reactive Arthritis, SLE  was ruled out with out any confusion.

Short Case 1 :

• Idiopathic Parkinson's Disease Stage 1 with denovo HTN.
• Multiple System Atrophy - Parkinsonian Type (MSA-P).

This case seemed to be very interesting to me that the patient is having resting tremors and prosody impaired.

Every system examination is done and presented with photographs.

The understanding of the case is made easy and their diagnostic approach is highly appreciable.

Short Case 2 :

IATROGENIC CUSHINGS SYNDROME SECONDARY TO TOPICAL CLOBETASOL APPLICATION ALL OVER BODY FOR APPROXIMATELY ONE YEAR.

TINEA CORPORIS

DENOVO HTN

The patient past history and present history of illness with the medication which he used previously are metioned clearly.

The signs and symptoms of the patient with pictographs are detaily explained.

The diagnosis to the case is very well done and treatment was appropriate.

Question 2 :

PROBLEM LIST OF CASE 1 :

• Had severe joint pains, which were initially asymmetric and gradually became bilaterally symmetrical and involving the small joints of his hands and wrist. The joint pains were associated with significant local edema, and painful limitation of movements, which made his job (stonemasonry) difficult. 
• Debilitating early morning pains and limitation of movements in his hands, wrists and feet, which usually lasts for about an hour, He reported that the pains and limitation of movements improved with activity, with gradual reduction in edema of joints.
• Joint symptoms gradually progressed in severity, now also involving several large joints
• Recently, has burning sensation in his eyes with increased tearing but no visual deficits. He also reported for the past 1 year, he developed subcutaneous swellings in the proximal joints of his fingers
• 3 day history of anasarca, frothy urine and gradually decreasing urine output.

this shows that Anasarca and frothy urine with decreasing urine output suggest a renal pathology. Proteinuria causing anasarca likely due to glomerular pathology. Pointing  acute development of glomerulonephritis secondary to poorly treated bilaterally symmetrical polyarthritis.

Diagnostic and therapeutic interventions :

Cardiovascular System - No abnormalities detected

Respiratory System - No abnormalities detected

Abdominal Exam - No abnormalities detected

Nervous System - No deficits detected

Investigations :

Standard 12 lead ECG with normal voltage and speed @ 25mm/s; P waves, QRS complexes and T waves have normal morphology and duration; P-P and R-R intervals are normal. PR and QTc intervals are normal.

X-ray AP view of the hands and wrists - Osteopenia and erosions of the MCP and PIP joints are noted. Scallop sign +. Significant soft tissue swelling is also noted.

Treatment

1. Free water restriction for Hyponatremia
2. Tab. PREDNISOLONE P/O 20 mg OD
3. Tab FEBUXOSTAT P/O 80 mg OD
4. Haemodialysis for worsening renal dysfunction

Short Case 1 :

Problem list :

• stiffness in his wrists (Right>Left), which has now ascended to his elbows. 
•  same involuntary movements also started appearing in his left hand. 
• difficulty in taking stairs up, in that he feels he sometimes might lose balance
• Involuntary movements - Resting tremors of Right upper limb , 3-4Hz, high amplitude.
  Gait - Reduced arm swing.
• Cog wheel rigidity at wrist joint
• Clarity in speech is decreased and plains of having ugly handwriting recently.

Diagnostic and therapeutic interventions

Parkinson's Disease is primarily diagnosed on

the basis of the four cardinal symptoms: tremor, bradykinesia, rigidity and problems with balance and gait.

Nervous System Examination was done.

Treatment

1. Tab. Syndopa Plus 125 mg QID

2. Tab. Syndopa 125 mg CR OD

3. Tab. Telma 40 mg OD

Management remains complex over the course of PD due to its progressive nature, individual patient heterogeneity, and wide range of signs, symptoms, and increasingly affected daily functions. However, the last 10-15 years have seen great progress in the identification, evaluation, and management of the disease, particularly in the advanced stages.

Short Case 2 :

Problem list :

• Itchy Ring leisons over arms ,abdomen ,thigh and groin since 1 and half year .
• Purple stretch marks all over abdomen ,lower back ,upper limbs ,thighs since 1 year .
• Abdominal distension and facial puffiness since 6 months.
• Pedal edema 
• Low back ache 
• Feeling low , not feeling to talk to anyone.
• Weight gain and decreased libido 
• Loss of libido and erectile dysfunction
• Thin skin present . 
• Poor healing noticed over leg ulcers and easy bruising noted .
• Acne present over face .
• Acanthosis nigrans noted over neck.
• GYNECOMASTIA PRESENT .
• Buffalo hump present .
• Sparse scalp hair

Diagnostic and Therapeutic Interventions :

INVESTIGATIONS :

CBP - HB - 13.4 g/dl 

TLC - 6,800

PLT - 1.5 lakhs.

RBS - 139 mg/dl 

CUE - ALBUMIN - +1 

SUGARS - NIL .

PUS CELLS - 3-4 

RBC - NIL .

LFT - TB -1.03

DB-0.21

ALBUMIN - 3.9

RFT - UREA - 22 

SERUM CREATININE -0.6

ELECTROLYTES - NA - 136 

K- 4 

CL-98 

USG ABDOMEN - NORMAL.

ECG - SINUS TACHYCARDIA 

LVH PRESENT.

Treatment :

Dose of Tab hizone was reduced to 10 mg per day in divided doses for one month.

In view of low back ache Xray LS spine was done which was normal and pt was advised.:

 Tab Shelcal 500 OD and Tab Vit D 3 Od.

Tab ULTRACET /PO/SOS.

Psychiatry opinion was taken and he was diagnosed with moderate depression .

Question 3 :

Long Case 1

Synovial histopathology is infrequently required in polyarthritis.

Histopathology is rather important for making the differential diagnosis of accompanying symptoms or in evaluating visceral organ involvement.

Short Case 1 :

Parkinson's Disease

Microscopically, the pathological hallmark of PD is the presence of abnormal cytoplasmic deposits within neuronal cell bodies which are immunoreactive for the protein α-synuclein. These pathological protein aggregates are called Lewy bodies (LBs) and are often accompanied by dystrophic neurites (Lewy neurites), which are mostly axonal.

Pathologically, the movement disorder occurs due to loss of dopaminergic neurons in the SNpc, with a number of other brain regions also being involved. The histopathological hallmark of PD are LBs, which predominantly contain aggregated α-synuclein, but it is not clear how these may result in neurodegeneration. Understanding these pathogenic processes can allow for the identification of novel therapeutic targets, and, hopefully, the development of disease-modifying treatments in the future.

Short Case 2 :

When patients are prescribed corticosteroids, all clinicians including the pharmacist must educate the patient about the side effects of these hormones and the need for close follow-up. The pharmacist should educate the patient on the prevention of peptic ulcer disease, diabetes, and weight gain.

All patients diagnosed with Cushing syndrome need long-term follow-up until the syndrome has been cured or eradicated. Finally, clinicians, nurses, and pharmacists should educate patients about the potential adrenal crisis if the corticosteroid is stopped abruptly.

Question 4 :      

I did not get chance to make my own log this month

Question 5 :

Testing scholarship competency in logging reflective observations on your concrete experiences of this last month

In the lockdown we are going through elogs which made us to come across the importance of history which is essential in pin pointing towards the clear Diagnosis.And also the importance of communication between doctor and patient because when we correctly know symptoms and patient's chief complaints from the patient our approach to diagnosis becomes a bit easier. Through these elogs we are learning lot of things and this knowledge will be useful when we attend clinical postings!!!

Thank you 

M.Laxmi Sowmya 

Roll No. 71

3rd Sem.