2nd internal assessment

Paper I






























Paper - II 

36 year old male with epigastric pain

A 36 year old male with epigastric pain

-

This is an online e logbook to discuss our patients deidentified health data shared after taking her/guardian's signed informed consent
Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs

This E log also reflects my patient centre’s online learning portfolio and valuable inputs on the comment box is welcome.







Case History



a 36 year old male , driver by occupation ,came to the casualty with 


CHEIF COMPLAINTS OF -


complains pain in the epigastric region since 8 days 


HISTORY OF PRESENTING ILLNESS -


patient was apparently asymptomatic 9 days back then he developed  pain in the epigastric region    which was   sudden in onset ,   dragging type of pain and non-radiating type ,   aggravated on sleeping in Lateral position relieved on medication. Tightness of the abdomen since 4 days
 High grade Fever since 9 days which was sudden in onset associated with chills and rigors and headache (frontal and occipital) . He developed shortness of breath since 5days (grade 2 )   constipation since 4 days  and decrease in appetite. 


complains of belching 2 to 3 times per day 

He had similar episode previously in June 2021 with complaint of pain and distended abdomen. 

no history of nausea vomiting , no h/o loose stool ,no history of past surgery 
no history of jaundice previously 
no history of gallstones, 


PAST HISTORY - 

Similar history 6months back , not a known case of htn , dm , epilepsy , asthma , tb
no previous surgical history 
no history of gallstones in the past


PERSONAL HISTORY :


diet - mixed ,

appetite -decrease appetite ,

bowel movement - irregular since 3 days, 

 bladder movements - regular ,

addictions(alcohol and smoking) - 

alcoholic in seven years takes at least 150 ml 
occasional toddy user also since six months drinks 180 ml per day 
 brand used it is (royal stag or ib )180 ml per day is in six months
 
no history of smoking or chewing tobacco



FAMILY HISTORY - 

not significant


GENERAL EXAMINATION -


patient is concious , coherent cooperative
no pallor , icterus Present - mild, clubbing , cyanosis , lymphadenopathy , edema




vitals - 

8-1-22
temperature - afebrile

pulse rate - 97 bpm

blood pressure - 100 /70 mm of hg 

respiratory rate - 22

spo2 - 98% at room air


SYSTEMIC EXAMINATION - 


cardiovascular system : s1 and s2 heard , no murmurs
respiratory system : bilateral air entry present ,normal vesicular breath sounds
central nervous system : nad

p/a -
Abdomen is slightly distended
Umbilicus central , inverted , all quadrants moving appropriately with respiration
No scars , engorged veins, no visible peristalsis or pulsations
pain in the epigastric region and 
pain is more in the right iliac and lumbar region
no bruit’s , no gaurding, no rigidity
negative cullens sign and grey turners sign, no fox's sign
bowel sounds present 




INVESTIGATION - 




Elevated serum amylase and lipase
Stool for occult blood positive


HEMOGRAM: 




CUE:



RFT:





CT scan











COMPLETE URINE EXAMINATION: 











PROVISIONAL DIAGNOSIS -

Acute pancreatitis
With alcohol dependence



TREATMENT GIVEN -


1 . ivf ns and rl and dns @ 50 ml /hr

2. ink . pantop 40 mg iv/od

3 .ink zofer 4 mg iv sos

4. inj tramadol 1 amp in 100 ml na iv bd

5.inj buscopan 22 cc iv/sos

6.tab pcm 650 mg po/tid 

7.grbs 6 th hourly

8 temp and i/o charting



Questions
What is the cause of shortness of breath?
What is the cause for Positive occult blood stool ?

INTERNAL ASSESSMENT 1

21 year old female with fever and generalized weakness

August 27, 2021

A Shishira Reddy
4th year MBBS


21 YEAR OLD WITH FEVER AND GENERALIZED WEAKNESS.

This is an online e logbook to discuss our patients deidentified health data shared after taking her/guardian's signed informed consent
Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs

This E log also reflects my patient centre’s online learning portfolio and valuable inputs on the comment box is welcome.

I would like to thank  DR.AASHITHA for providing me with the case details. 

Case:-

21 year old woman, working as a nurse in an outside hospital,  presented to casualty on 26/8/2021 with the chief complaints of 
Fever since 4 months 
Generalized weakness since 4 months
Body pains along with multiple joint pains since 4 months
Cough since 1 month 
Vomiting 1 day back 
Unable to walk since 1 day
Unable to pass urine and stool since 1 day

 
History of presenting illness

She was apparently alright until 1 year back when she noticed swelling in her neck after she went for a checkup to a local hospital where she got diagnosed to be hypothyroid. She was started on Tab thyronorm 100mcg once daily.


Few months later she developed generalized weakness for which she paid a visit to a local hospital where in she was diagnosed with anemia for which she used vitamins supplementation for 2 days and stopped.

4 months back she developed low grade fever for 1 week which was nocturnal in variation, not followed by night sweats and was relieved by medications. Since then she has been experiencing low grade fever intermittently. She started experiencing generalized weakness and loss of appetite. 
She also tells us that she started experiencing extreme body pains to an extent that she stopped going to work. She even developed lower back pain followed by pain in her bilateral knee joints, wrists and elbow joints.

Since 1 month she has been having cough with scanty, non blood tinged mucoid expectoration.
She paid a visit to a local hospital and received symptomatic treatment for a week.
1 day back she had 2 episodes of non projectile, non bilious, 
non blood tinged Vomiting.

On 26th of this month, she suddenly fell off from her bed at 7am in the morning when she tried to get up from her bed. Her mother and father had to lift her up and put her on the bed. She was unable to raise her bilateral lower limbs. Though she was able to move her toes with difficulty. Few hours later she started experiencing tingling sensation in her bilateral lower limbs. They assumed it was due to her generalized weakness and loss of appetite so she wasn't taken to any hospital. She even didn't pass urine and stool since morning. By evening after noticing that their daughter couldn't get up from her bed her parents got alarmed and got to our hospital.

On further questioning:

She gave no complains of difficulty in combing her hair, no difficulty in mixing of food. 
She had difficulty in getting up or turning in the bed

She gave no complaints of loss of smell, vision, diploma or eye movements, no difficulty in chewing, loss of sensation over the face, loss of taste, hearing and swallowing.

She says that she lost around 10kgs over the past 6 months


General examination: 

On presentation to us:              
Thin built woman           
She had pallor
Her vitals were stable
GCS - 15/15
She was conscious, coherent and cooperative with an 
MMSE of 30/30
Pupils bilaterally reacting to light
Bulk - Right Left
Mid arm 18cm 18cm
Forearm 13cm 13cm
Mid thigh 26cm 26cm
Leg 18.5cm 18.5cm

Tone          
UL Reduced bilaterally
LL Reduced bilaterally 

Power
UL 4+/5 4+/5
LL 2/5 2/5

Reflexes
B 3+ 3+
T 2+ 2+
S 3+ 3+
K - - 
A - -
P Extensor bilaterally
Abdominal reflex - Absent 

Sensory system:
Priopioception lost upto the level of ankles
Vibration: Reduced in the lower limbs, more on the right side   
                     Right Left

Great toe 3 secs 4 secs
Ankle 3 secs 8secs
Knee 6 secs 8secs
Wrist 10 secs 11 secs
Elbow 11 secs 12 secs
Fine touch - + +

Crude touch: 
On right side she complained of reduced touch on her right thigh
Spinal Tenderness- present throughout all the levels of spine 

Cranial nerves - normal 
Cerebellar signs - absent 


Lungs - Reduced breath sounds bilaterally in all the lung fields
Cvs - S1,S2 +
Per Abdomen- 
Bowel sounds +


28/7/21
Her sister and mother complained of her having left eyelid ptosis and she was complaining of diplopia in the morning 
Her weakness aggravated since yesterday 
She also complains of neck stiffness 

Neck stiffness+

Kernigs sign - couldn't be elicited as she is complaining of severe bilateral knee joint pains 

Power is now 0/5 in both the lower limbs

Reflexes - Bilateral finger flexion + on Biceps and supinator examination 
Lower limb reflexes absent 
Abdominal reflex absent

Sensory system:

Vibration Reduced upto the level of hip joint ( lesser on the right side)
Proprioception absent upto the level of ankles
Couldn't appreciate fine and crude touch below the level of umbilicus

Left eye ptosis +
Extraocular muscles - normal 
Pupils bilaterally reacting to light 
All the other cranial nerves normal

Investigations:

Hemogram: 
RBC: 4.09
WBC: 12300
Hb- 8.4
PLT- 4.8 lakh

Aptt- 32 sec
PT - 16 sec
INR. - 1.11
BT - 2 min 
CT - 4 min 
ESR - 90 mm in 1st hr

CUE: 

Albumin- nil
Sugars- nil
Pus cells - 2 to 3
Epithelial cells - 2 to 3

Blood urea- 22 mg/dl
Serum creatinine - 0.6 mg/dl 
TB- 0.70 mg/dl 
DB. - 0.19 mg/dl 
Na+ - 132 meq/lit
K+ - 3.4 meq/lit
Cl- : 94 meq/lit
ALP: 236 IU/lit
SGOT: 13 IU/LIT
SGPT: 10 IU/LIT
Serum protein: 6.5 gm/dl 
Serum magnesium: 2.2 mg/dl
Serum calcium: 9.6 mg/dl
Serum albumin: 2.4 gm/dl

Covid-19- Negative 

Peripheral smear- Microcytic hypochromic anemia with leucocytosis 

MRI BRAIN IMPRESSION- Acute infarct involving the genu of the corpus callosum on the left side

Provisional diagnosis:

PULMONARY KOCH'S 
B/L PARAPLEGIA
HYPOPROLIFERATIVE ANEMIA SECONDARY TO NUTRITIONAL ANEMIA 








Treatment -

On 26-08-2021:-
1) IV FLUIDS NS
2) Inj.Optineuron 1 ampoule in 100 ml NS IV/OD
3) Inj.Pan 40 mg IV/OD

On 27-08-2021:-
1) IV FLUIDS NS,RL@100ml/hr
2) Inj.Optineuron 1ampoule in 100ml NS IV OD
3) Inj.Zofer 4mg IV/TID
4) Tab.pcm 650 mg PO SOS
5) Inj.Neomol IV SOS if temp>101°f
6) Nebulization with Duolin and budecort 6th hrly
7) Syr.Ambroxol 5ml PO TID
8) TAB.Thynonorm 50 mcg PO OD
9) TAB.Ultracet PO QID
10) TAB.Ecosporin 75mg PO H/S
11) TAB.Atorvas 10 mg PO H/S
12) TAB.Clopidogrel 75 mg PO H/S

On 28-07-2021:-

1) IV FLUIDS NS,RL@100ml/hr
2) Inj.Optineuron 1ampoule in 100ml NS IV OD
3) Inj.Zofer 4mg IV/TID
4) Tab.pcm 650 mg PO SOS
5) Inj.Neomol IV SOS if temp>101°f
6) Nebulization with Duolin and budecort 6th hrly
7) Syr.Ambroxol 5ml PO TID
8) TAB.Thynonorm 50 mcg PO OD
9) TAB.Ultracet PO QID
10) TAB.Ecosporin 75mg PO H/S
11) TAB.Atorvas 10 mg PO H/S
12) TAB.Clopidogrel 75 mg PO H/S
13) Protein powder 2 spoons in 100ml milk PO /BD

On 29-08-2021:-

1) IV fluids
2) Inj optineuron 1ampoule in 100 ml NS/IV/OD
3) Inj.zofer 4mg IV/ TID
4) Inj.neomol 1g IV SOS
5) Inj methyl Prednisolone 500mg IV/OD in 100ml NS (DAY 3)
6) ATT(H-150mg R-300mg E-450mg Z-750mg)
7) Nebulization with duolin and budecort 6th hrly
8) Tab.thyonorm 50 mcg PO OD
9) Syp creamffine plus PO/TID
10) Syp ambroxal 5ml PO/TID
11) Tab ecospirin 75mg PO/OD
12) Tab atorvas 10mg PO/H/S
13) Tab Benadon 40mg PO OD


On 30-08-2021:-

1) IV fluids
2) Inj optineuron 1ampoule in 100 ml NS/IV/OD
3) Inj.zofer 4mg IV/ TID
4) Inj.neomol 1g IV SOS
5) Inj methyl Prednisolone 500mg IV/OD in 100ml NS (DAY 3)
6) ATT(H-150mg R-300mg E-450mg Z-750mg)
7) Nebulization with duolin and budecort 6th hrly
8) Tab.thyonorm 50 mcg PO OD
9) Syp creamffine plus PO/TID
10) Syp ambroxal 5ml PO/TID
11) Tab ecospirin 75mg PO/OD
12) Tab atorvas 10mg PO/H/S
13) Tab Benadon 40mg PO OD
14) Tab.Pregabiline 75mg PO H/S

On 31-08-2021:-

1) IV fluids
2) Inj optineuron 1ampoule in 100 ml NS/IV/OD
3) Inj.zofer 4mg IV/ TID
4) Inj.neomol 1g IV SOS
5) Inj methyl Prednisolone 500mg IV/OD in 100ml NS (DAY 5)
6) ATT(H-150mg R-300mg E-450mg Z-750mg)
7) Nebulization with duolin and budecort 6th hrly
8) Tab.thyonorm 50 mcg PO OD
9) Syp creamffine plus PO/TID
10) Syp ambroxal 5ml PO/TID
11) Tab ecospirin 75mg PO/OD
12) Tab atorvas 10mg PO/H/S
13) Tab Benadon 40mg PO OD
14) Tab.Pregabiline75 mgPO H/S

On 01-09-2021:

1) IV fluids
2) Inj optineuron 1ampoule in 100 ml NS/IV/OD
3) Inj.zofer 4mg IV/ TID
4) Inj.neomol 1g IV SOS
5) Tab.wysalone PO/OD
6) ATT(H-150mg R-300mg E-450mg Z-750mg)
7) Nebulization with duolin and budecort 6th hrly
8) Tab.thyonorm 50 mcg PO OD
9) Syp creamffine plus PO/TID
10) Tab ecospirin 75mg PO/OD
11) Tab atorvas 10mg PO/H/S
12) Tab Benadon 40mg PO OD
13) Tab.Pregabiline 75mg PO H/S
14) Tab.levipil 250 mg PO/BD

On 02-09-2021:-

1) IV fluids
2) Inj optineuron 1ampoule in 100 ml NS/IV/OD
3) Inj.zofer 4mg IV/ TID
4) Inj.neomol 1g IV SOS
5) Tab.wysalone PO/OD
6) ATT(H-150mg R-300mg E-450mg Z-750mg)
7) Nebulization with duolin and budecort 6th hrly
8) Tab.thyonorm 50 mcg PO OD
9) Syp creamffine plus PO/TID
10) Tab ecospirin 75mg PO/OD
11) Tab atorvas 10mg PO/H/S
12) Tab Benadon 40mg PO OD
13) Tab.Pregabiline 75mg PO H/S
14) Tab.levipil 250 mg PO/BD

Questions 

1) Is pulmonary koch's a cause for nutritional anemia and generalized weakness?

2) what is the possible cause of infarction in the left side  corpus callosum?

3) what is the cause of paraplegia in the patient? 

65 year man with Dyspnea on exertion and bilateral lower limb edema

A 65 year old from ********* presented with

 the complaints of 
Bilateral lower limb swelling since 1 month 
Dyspnea on exertion since 20 days
Black coloured stools since 20 days 


History of presenting illness

A 65 year old man, previously used to work as a farmer 6 years back, got married to his far relative and has been happily married with 3 children.

 He has been an occasional alcoholic and a beedi smoker and smokes around 3 to 4 beedis per day. He smoked last 3 months back.

25 years back, his left index finger was amputated after it got hit by a tractor.

20 years back he got into a fight with his friends following which he had a trauma to his head following which he had one episode of seizure and he was put on antiepileptics, which he used for 3 years and stopped.

Since 6 years - He has been experiencing bilateral knee joint pains so much that he stopped working. He paid a visit to our hospital and was advised for a total knee replacement. However, on further investigating him he was told that he had a heart condition because of which he cannot be operated.

He first developed pain in his right knee following which he developed left knee pain. Over the past 1 month he has even developed pain in his bilateral wrist joint, following which he developed pain in his bilateral elbow joint and shoulder joints.

2 years back - He paid a visit to a hospital for difficulty in seeing far objects for which he was prescribed spectacles, then he got even diagnosed to be a diabetic and has been on irregular medications since then 


Since 1 month - He developed bilateral lower limb swelling, first he says he developed upto his ankles which gradually progressed to his thighs over a month.

Since 20 days he also has been experiencing dyspnea on walking for short distances and he also started noticed jet black coloured stools.

He also says he has to wake up from his sleep 4 times everyday to pass urine. He says he passes urine frequently but in small quantity. 


Patient is a thin built man 
Pallor +
Bilateral pitting type of pedal edema extending upto thighs +

PR - 110bpm
BP - 90/60mmhg
RR - 18 cpm
Spo2 - 99%
GRBS - 150mg/dl
JVP raised


Systemic Examination:
On Inspection :
Apical impulse visible



Showing bilateral lower limb pitting edema extending upto thighs



Chest measurements:
Transverse - 23 cm
AP diameter - 19 cm

Inspection:


Palpation: 
Palpable apex beat
Apex beat palpated in 6th ICS 1 cm lateral to the Midclavicular line 
No palpale pulsations in aortic and Pulmonary areas
No palpable pulsations in sternoclavicular area
No left parasternal pulsations
No epigastric pulsations palpable

Auscultation:
 S1,S2 +

Respiratory system -
Bilateral airway entry +
Clear

Per Abdomen- 
Non tender
Bowel sounds +

Provisional diagnosis:
1.Anemia under evaluation 
2.Heart failure with preserved ejection fraction 

A 38 year old male with chief complaints of forgetfulness and irrelevant talking.

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent.Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs". This E log book also reflects my patient-centred online learning portfolio and your valuable comments on comment box is welcome. 

Name : A Shishira Reddy

Roll. No. 02 

8th Semester

Following details were  provided to me by Dr. Raveen sir and Dr. Arun sir. 

Case history :

A 38 year old male patient, presented to the OPD with the chief complaints of  

1. forgetfulness since 3 months,  

2. irrelevant talk since 3 months, and 

3.gait disturbances since 2 months.

History of presenting illness :

Patient was apparently asymptomatic 3 years back when he developed pain abdomen and was admitted to various hospitals and was diagnosed with acute pancreatitis.

He was diagnosed with type 3 diabetes mellitus, (secondary to acute pancreatitis) 3 years back. Since lockdown, he has been consuming more than 1litre of whiskey per day. 

 3 months back he consumed only  alcohol without any food for one week, and One day morning, the attenders were unable to wake him up from sleep. He was taken to Mamatha medical College where he was diagnosed with alcoholic ketosis and was on treatment for 2 weeks . Since then , he has not been able to talk, he has not been able to respond to command. He has been unable to remember things , has not been able to do things by himself.

Past history:

 patient is a known case of type 1 diabetes mellitus since 3 years and was on medication. 

Personal history:

Married

Appetite:  normal 

Diet:  mixed 

Bowel and bladder habits :  regular

Sleep:  adequate

Addictions :   alcoholic since 8years , used to consume 1litre of whiskey per day; 

smoked 2-4 cigarettes daily since 1 year. 

Family history: not significant.

General examination: 

The examination was done after obtaining informed consent in a well lit room.

The patient was conscious, well oriented to persons, Not oriented to place and time. 

There was no pallor, icterus, clubbing, cyanosis, lymphadenopathy, and edema. 

Vitals :

Temperature : afebrile

Pulse rate : 70bpm

Respiratory rate : 20 cps

Blood pressure : 110/70 mmHg

SpO2 : 99% at room temperature. 

GRBS : 269 mg/dl

Cvs: 

S1, S2 heard 

Respiratory system: Bilateral air entry is present. 

Abdomen: 

Soft, No tenderness, no palpable mass. 

Central nervous system :

  Conscious, not oriented to time , place and person 

Speech: no response.

No signs of meningeal irritation ( no neck stiffness, kerning's sign negetive)

Pupils - NRSL

Rombergs sign - negetive

   

                                         Right.                    Left 

Tone- UL.                            N                          N

           LL.                            N                          N

Power- UL                         5/5                       5/5

              LL.                        5/5.                      5/5

Reflexes.        

             B.                             +2.                          2+

             T.                              +2.                          2+

             S.                              +2.                          2+

             K.                                -   Not    elicited   -

             A.                               +.                             +

             P.                       decreased.          decreased

Lobar function:

Frontal lobe : unable to perform problem solving, lack of insight.

Parietal lobe : able to perform series of motor activities.

Right and left orientation ---->positive

Finger recognition ---->positive

Visuo-spatial orientation ----> negetiv

Occipital lobe : able to recognise familiar faces. 

Investigations:

Hemogram-   

Normocytic normochromic 

Urine examination-

RFT -

UREA.                 :  14mg/dl

CREATININE.     :  0.8 mg/dl

PHOSPHORUS  :  4.6 mg/dl

SODIUM            :  138 mEq/L

POTASSIUM     :  4.6 mEq/L

CHLORIDE        :  99 mEq/L

LFT- 

AST : 16 IU/L

ALT : 10 IU/L

ALP : 180 IU/L

TOTAL PROTEINS : 6.5 mg/dl

ALBUMIN : 3.77 mg/dl

A/G RATIO : 1.38 

ECG-

Vent rate : 60BPM

PR interval : 138ms

QRS duration : 74ms

QT/QTc : 419/419ms

Avg RR : 996ms

P-R-T axes : 12  23  34

MRI

Mild diffusely thinned out Corpus callosum.

Normal grey/white matter differentiation

Nasal ganglia and thalami are normal

Cranio-vertebral and Cervico-medullary junctions are normal.

Sella, pituitary and parasellar regions are normal. 

Pituitary gland, pituitary stalk, and hypothalamus are normal. 

Provisional diagnosis:

Alcohol induced dementia 

K/c/o type 1 diabetes mellitus

K/c/o alcohol dependence syndrome. 

Treatment:

Inj. Thiamine 2amp in 100ml NS /IV/ TID

Inj. Human Mixtard S/C -- 

Tab. Haloperidol 165mg PO/OD

Tab. Pregabalin 75mg PO/MS 

Tab. Divalproate 100mg 

Tab. Memantine 10 mg 

Tab. Sprolit plus 1/2 tab OD