BIMONTHY ASSIGNMENT........ELOG BY SAI PRANEETH BATHINEEDI
E-lOGS OF GENERAL MEDICINE CASES
BIMONTLY ASSESSMENT FROM GENERAL MEDICINE DEPARTMENT
NAME:SAI PRANEETH BATHINEEDI
ROLL NO:116
3 SEMESTER STUDENT
This is an online e log book to discuss our patient de-identified health data shared after taking his/her/guardians signed informed consent.
Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evidence based input
I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.
QUESTION 1; STUDY THE CASE AND BRIEF UP THE SUMMARY ALONG WITH OPEN SUGGESTIONS IF ANY
CARDIOLOGY; A CASE OF ACUTE CORONARY SYNDROME
A 67 Years Old Female Patient came to the OPD with chief complaints of shortness of breath(SOB) since 1\2 hour(which started at midnight and contd. even at rest along with sweating on exertion) ;
she has-
H\O Heartburn like episodes since 1 year which used to be relieved without any medication;
K\C\O tuberculosis diagnosed 7 months back for which she was on a 6 month course of medication(negative at present);
K\C\O DM TYPE 2 for 12 years(RX GLIMI M2 PO\OD) and HYPERTENSION since 6 months (RX TELMA 20 mg PO\OD);
On Examination she had Inspiratory crepts and is dysnoeic;
"NO OTHER SIGNIFICANT HISTORY"
The ECG showed findings of NSTEMI( Non ST elevation of myocardial infarction)
*depressed ST wave or T-wave inversion
*no progression to Q wave
*partial blockage of the coronary artery
The Patient was given TAB MET XL 25 MG\STAT on seeing the ECG Findings; Metoprolol is used as along acting beta blocker which controls high blood pressure.
The patient was then referred to cardiac Hospital for PCI(Percutaneous Coronary Intervention) which was not done on the patient due to non vacancies for the procedures at another hospital and she was discharged and when enquired she was doing fine lately.
NOTE:
Percutaneous coronary intervention (PCI), also known as coronary angioplasty, is a nonsurgical technique for treating obstructive coronary artery disease, including unstable angina, acute myocardial infarction (MI), and multivessel coronary artery disease (CAD).
In addition to the above information it would have been more precise if the grade of SOB was mentioned along with marking of the ECG findings on the Graph.
PULMONOLOGY; VIRAL PNEUMONIA SECONDARY TO COVID19
A70 yr old man came to the OPD with chief complaints of Fever and dry cough since 10 days and shortness of breath(SOB) for 4 days;
The fever was insidious in onset without chills and rigor;
The SOB was of Grade-3(MMRC Grading);
He was mildly Dehydrated and "REST OF THE HISTORY IS INSIGNIFICANT"
He was tested positive for COVID19 with RTPCR TEST.
VITALS EXAMINATION;
Temperature was around 98.6 on an average,spo2 was 86%,92%,96% and consistent on 4 days after admission respectively.
ALTHOUGH the GRBS(general random blood sugar)was ABNORMAL(ABOVE 300Mg\dl) knowing that he is NOT A KNOWN CASE OF DM.
*THIS was a very well presented case except for the fact that the chest CT was not ordered for confirming the diagnosis of viral pneumonia and the WBC count was decreased which was supposed to increase in case of any infection(viral infection in this case).
They treated him withO2 inhalation @NIV to maintain SPO2 >90% and dexamethasone injection for supressing the inflammation and infection. Nebulisation with Duolin,budecort,mucomyst 8th hourly and ghrelintus for the dry cough alon with paracetomol and vitamin c tablets.
NNEUROLOGY; ACUTE CORTICAL VEIN THROMBOSIS WITH HEMORRHAGIC VENOUS INFARCTION(right posterior temporal lobe)
A 17 years female,student by occuption came to the OPD with chief complaints of involuntary movements of both the upper and lower limbs since 1 day;
Patient was apparently asymptomatic one day ago, then she developed recurrent involuntary movements of all four limbs associated with loss of consciousness and frothing. And with recovery of consciousness in between episodes with post ictal confusion lasting for 30 secs to few minutes;
she had 56 episodes in 24 hrs;
She continued to have multiple GTCS episodes with a frequency of one in 20 minutes.
she complains of;
*Headache which was right sided,intermittent ,dull aching type.
*vomitings:1 episode of vomiting bilious,containing food particles.
"NO OTHER SIGNIFICANT HISTORY FOUND" other than the routine normal history.
Kerning sign: negative rules out meningitis.
The CBC panel revealed some abnormalities in the WBC count alog with low haemoglobin and pallor which is suggestive of iron deficiency anemia.
MRI SCAN revealead IMPRESSION ON MRI:F/S/O Acute cortical vein thrombosis with hemorrhagic venous infarction involving Right posterior temporal lobe with midline shift to left by 4mm.
Recurrent seizures(seizure clusters/status epilepticus)resolved secondary to cortical vein thrombosis with hemorrhagic venous infarction in right posterior temporal lobe with (4mm midline shift).
Iron deficiency anemia.;
THIS CASE WAS VERY WELL PRESENTED WITH COMLETE DETAILS OF THE PATIENT AND THE DIAGNOSIS WAS PRECISELY MADE AFTR REWIEING THE MRI SCAN AND THE SUBSEQUENT TREATMENT PLAN WAS MADE WHICH WAS FOLLOWED BY HER DISCHARGE.
NEPHROLOGY; POST TURP(TRANS URETHRAL RESECTION OF PROSTATE) WITH NON OLIGOURIC ATN(ACUTE TUBULAR NECROSIS)
A 52 yr old man farmer by occupation came to the OPD which chief complaints of pus in urine and fever since 4 days.
He complaints that 1 year back, he gradually developed drippling of urine, Hesitation, reduced flow of urine, Difficulty in void initially not associated with suprapubic pain or burning micturition
But,since 3 months patient had burning micturition not associated with fever or suprapubic pain then he consulted a urologist, where he was told , He had Prostomegaly (60gm) and advised TURP for which he underwent operation. He had some slight complications after the operation for which he visited the OPD for 3 times and the 4 time,There is a history of fleshy mass like and foamy passage in his urine 6 days back (as said by patient's attender) along with pus in the urine and high grade fever.
K\C\O DM TYPE 2 FIVE YEARS BACK FOR WHICH HE IS ON MEDICATON.
He was ordered NCCT KUB;
HYDRONEPHROSIS;
right kidney is more effected than the left one and phleboliths are seen in the ureter.
* Bilateral Hydroureteronephrosis, severe on right side and moderate on left
* Urinary bladder shows diffuse circumferential wall thickening( 6 -7mm)
* No obvious obstructing lesion in urinary tract
DIAGNOSIS:Renal AKI secondary to urosepsis with b/L hydroureteronephrosis with K/c/of DM -2 since 5 yrs with diabetic nephropathy with Anemia secondary to CKD with grade 1 bed sore;
He was given treatment accordingly and discharged after a couple of days.
THIS WAS A VERY GOOD PRESENTATION MADE BY OUR SENIOR BUT IT WOULD HAVE BEEN BETTER IF FEATURES OF ACUTE TUBULAR NECROSIS HAD BEEN MENTIONED ALONG WITH PROOVING THAT THIS IS THE CASE OF ATN.APART FROM THIS THE HISTORY WAS VERY WELL TAKEN WITH ALL THE MINUTE DETAILS.
NEUROLOGY; RIGHT SIDED CVA WITH ACUTE INFARCT IN SOME PARTS OF BRAIN.
A 30 yr old man lorry driver by occupation came to the OPD with chief complaints of right sided weakness of upper and lower limb and deviation of mouth towards left side since one day;
He was traumatized for some family problems and was under hot climate for 10-15 days;
K\C\O alcoholic(once a week 500ml);
apparently he was not drunk when he had a sudden fall at his relatives house which were not associated with any involuntay movements or frothing;
NO COMPLAINTS OF vomiting,headache,chestpain,palpitations,blurring of vision.
He has a H\O RTA where there was shoulder dislocation along with displacement of mandibular and zygomatic process.
HE IS DROWSY AND DISORIENTED TO TIME, PLACE AND PERSON;
NO OTHER SIGNIFICANT HISTORY OTHER THAN THE ROUTINE HISSTORY
REFLEXES : LEFTSIDE-Withdrawl reflex,
RIGHTSIDE-Extensor reflex.
PUPILS: RIGHT SIDE-RIGHT :Dilated -Non reactory to light
LEFT SIDE-LEFT : Normal- Reactory to light
RELEVENT INVESTIGATION;
MRI SCAN-
CLINICAL IMAGES;
PROVISIONAL DIAGNOSIS WAS MADE AS RIGHT SIDED CEREBROVASCULAR ACCIDENT WITH ACUTE INFARCT IN LEFT INTERNAL CAPSULE ,CAUDATE NUCLEUS,PUTAMEN,LEFT THALAMUS,LEFT INSULAR LOBE,PRECENTRAL GYRUS(ACUTE INFARCT IN LEFT MCA TERRITORY)
THIS CASE HAD BEEN PRESENTED WELL WITH ALL THE RELEVANT HISTORY AND CLINICAL DATA NEDED TO ARRIVE AT A DEFINITIVE DIAGNOSIS AND THE PATIENT SHOULD HAVE BEEN REFERRED TO PSYCHIATRY DEPARTMEENT SINCE HE HAS TO GET RID OF THE TRAUMA WHICH HE HAS UNDERGONE.
NEUROLOGY ; ALTERED SENSORIUM- WERNICKIES ENCEPHALOPATHY SECONDARY TO CHRONIC ALCOHOL DEPENDENCE;
THIS WAS A BEAUTIFUL PRESENTATION MADE WHICH INCLUDES THE ACTUAL CLINICAL IMAGES OF THE PATIENT ALONG WITH WIDE RANGE OF INVESTIGATIONS DONE.I SIMPLY WOULD HAVE DONE NO BETTER THAN ADDING THR RELATIONSHIP BETWEEN THE CONSUMPTION OF EXCESS ALCOHOL WTH THAT OF THIAMINE DEFICIENCY;I WOULD ALSO REFER THE PATIENT TO PSYPHIATRY DEPARTMENT FOR SOME REHABILITATION FOR HIS ADDICTION TOWARDS THE ALCOHOL.
GASTROENTEROLOGY AND PULMONOLOGY;
THIS CASE WAS PRESENTED WITH CLEARCUT EXPLANATION AND DIAGNOSIS WAS MADE FOR THE SAID SYMPTOMS WITH THE HELP OF DETAILED HISTORY AND PRECISE INVESTIGATIONS AND THE TREATMENT PROCESS WAS EXPLAINED IN DETAIL AND THE MANUAL DIAGRAMS HAD HELPED ME TO ANALYZE THE RELATIONSHIP BETWEEN PANCREATIC PSEUDOCYST AND DEVELOPMENT OF BRONCHO-PLEURAL FISTULA.
CARDIOLOGY; PERICARDIAL EFFUSION AND ACUTE PERICARDITIS
ALTHOUGH THIS CASE IS MUCH FASCINATING THE END RESULT(PERICARDIAL EFFUSION SIZE) SUBSIDED WITHOUT ANY MEDICATION OR INTERVENTION WHICH IS QUITE A QUESTION .THE CASE WAS VERY WELL TAKEN AND PRESENTED WITH MUCH DETAILED FOLLOWUP OF THE PATIENTS STATUS WHICH INCLUDED FREQUENT ECHO AND USG SCANNINGS.
QUESTION 2; A BLOG ON A DETAILED CASE STUDY
QUESTION3&4; CASE LINK;
A 45 years old man came to the OPD with chief complaints of Altered sensorium ,lethargic since morning and fever for 3 days 10 days back;
He has B\L Pedal Edema along with Anasarca and shortness of breath(SOB) even at Rest.
He was apparently assymptomatic 5 years ago and when he developed lower back pain he was diagnosed with chronic kidney disease(high creatinine of 11mg\dl);
GRBS-206mg\dl NOTE:Apparently he is not a K\C\O DIABETIC despite which his blood sugar is high which indicates he might be more prone to DIABETES or a K\C\O DIABETES.
His pallor could be justified knowing his HB levels in the blood;
He was given bicarbonate to bring back the PH since he was acidotic;
He was given lasix TAB for the anasarca and pedal edema;
This case was presented beautifully except for the fact that the role of hypertension in causing nephropathy was not clearly mentioned and how uraemic encephalopathy causes altered sensorium- if the answers were to be addressed before then the case would have been very well understood even for beginners(initial years of med school) like us but other than this the collection of patients history was extensive and the treatment was given accordingly.
QUESTION 5; REVIEW ON SCHOLARSHIP COMPETENCY BASED MEDICAL EDUCATION;
LOGGING THE CASES ELECTRONICALLY HAS IMPROVED MY ABILITY TO USE TECHNOLOGY IN HAND WITH MY CLINICAL AND SUBJECTIVE KNOWLEDGE ON UNDERSTANDING THE PATHOPHYSIOLOGY OF THE UNDERLYING DISEASE OF A PARTICULAR DIAGNOSIS;
IT HAS THE UNIQUE WAY OF DRAGGING THE SUBLEVEL TIER WORKERS(MED STUDENTS)OF THE MEDICAL SYSTEM INTO ACTUAL WORK ATMOSPHERE AT THE HOSPITAL;
IT BRIDGES THE COMMUNICATION GAP BETWEEN THE VARIOUS TIER SYSTEMS OF MEDICAL EDUCATION BY WHICH I MEANT TO SAY WE GET AMPLE OPPURTUNIERS TO INTERACT AND LEARN FROM DOCTORS AND PATIENTS AS WELL;
THIS WOULD ACT LIKE A STRONG FOUNDATION FOR APPROACHING SOME UPCOMING RESEARCH OPPURTUNITIES IN THE NEAR FUTURE;
THIS BRINGS THE WORLD TOGETHER AS "GLOBAL VILLAGE" WHERE DOCTORS FROM VARIOUS PLACES COULD REACH OUT TO THIS BLOGS THROUGH INTERNET ACCESS AND REACT TO THE CASE AND COMMENT ACCORDINGLY;
AT LAST I WOULD LIKE TO SAY THAT THIS KIND OF TRANSFORMATION IN THE MEDICAL EDUCATION WOULD ADD A FEATHER TO THE CUP OF ACHIEVEMENTS TO OUR INSTITUTION OR COUNTRY.
I WOULD LIKE TO THANK THE ENTIRE GENERAL MEDICINE DEPARTMENT AND THE INTERS FOR HELPING ME TO COMPLETE THIS BLOG😇😇😇
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