Bimonthly blended assessment - June 2021

 Name : Pravallika Gade 

Roll no : 41 

Batch : 2019 ( 3rd sem)

 

 QUESTION 1

1. Pulmonology:

Review: https://166sasirakasinadhuni.blogspot.com/

Case: https://soumyanadella128eloggm.blogspot.com/2021/05/a-55-year-old-female-with-shortness-of.html 

This is a case of exacerbation of COPD due to possible RHF and bronchiectasis  presenting with shortness of breath , generalised weakness , pedal edema, facial puffiness , drowsiness and decreased urine output.

She’s a known case of diabetes and hypertension. An examination of all the systems and required investigations were done and possible right heart failure along with bronchiectasis was diagnosed. Due to already obstructive lung disease which increased the load on the right heart causing RHF. Bronchiectasis was another complication of COPD. Required medication for treating the symptoms was given like diuretics, steroids and antibiotics.Other associated therapies such as chest physiotherapy, thiamine and head end elevation was recommended. The patient was examined thoroughly and adequate investigations were done. The treatment for all the symptoms were given and I think the case was handled well. The placebo effect was explained well. 

2. Neurology: 

Review: https://171mkfarhanelogcases.blogspot.com/2021/05/online-blended-bimonthly-assignment.html 

Case: 

https://143vibhahegde.blogspot.com/2021/05/wernickes-encephalopathy.html 

This is a case of Wernicke's encephalopathy secondary to chronic alcohol dependence, Uraemic encephalopathy and Alcohol Withdrawal delirium. The primary etiology was identified to be alcohol. Alcohol is known to cause profound effects on the nervous system which is clearly shown in the above case. Worrisome symptoms such as seizures , memory loss and delirium were seen. Excessive drinking excites and irritates N.S.Body will be dependent on daily basis for alcohol. CNS cannot adapt with without alcohol. Cessation of alcohol leads to alcohol withdrawal symptoms. The need for thiamine in the treatment was explained well in the given review. Kidney failure exacerbated anemia due to reduction of erythropoetin and ulcers for aggravated due to alcoholism. The treatment outlined all required medications to resolve all the presenting symptoms and underlying causes to the greatest extent possible and recovery will depend on the patients adherence to the treatment regimen.

3. Nephrology and urology : 

Review: https://shubankarkandukuri.blogspot.com/2021/05/general-medicine-assignment-may-2021_77.html 

Case:

https://kavyasamudrala.blogspot.com/2021/05/medicine-case-discussion-this-is-online.html 

This is a case of acute renal failure secondary to urosepsis in a patient who is a known case of DM. Patient presented high grade fever and pus in urine . It has to be noted that the most recent admission was his 4th admission. Previously, he presented with multiple complaints i.e dribbling urine , suprapubic pain , drowsiness , excessive sleep and burning micturition. Upon some of the examinations during previous admissions prostatomegaly was seen and he underwent TURP for resolving the same. During the most recent admission , renal function tests were all impaired and a KUB xray was done which showed bilateral hydronephrosis and dilated ureters along with thickened wall of urinary bladder and tiny calcific focus in the pelvis. Adequate treatment was given covering antibiotics , diuretics, antipyretics and analgesics along with Vit. B12 and insulin. Given the chronic disease of the patient with associated cpmplications , the recovery process could take a long while.

4. Gastroenterology:

 Review: https://shubankarkandukuri.blogspot.com/2021/05/general-medicine-assignment-may-2021_77.html 

Case: https://vyshnavikonakalla.blogspot.com/2021/05/a-40-year-old-lady-with-dysphagia-fever.html

This is could be a case of tracheoesophageal fistula or oral candidiasis or oesophageal strictures. Tracheoesophageal fistula which is a congenital defect which causes the trachea and oesophagus to have communicating pathway between them causing the contents of both structures to mix resulting in symptoms such as dysphagia ,cough and sputum. It could also be oral candidiasis or oesophageal strictures. She also has AIDS. The presenting symptoms can be due to opportunistic infections. Anti retroviral therapy with other required regimen was given. It should be noted that she is TB positive. Given the illness , it is unlikely that she will recover and her AIDS will progress and prove to be fatal. All we can do is make sure we treat the associated ailments to make her life comfortable.

5. Infectious diseases and hepatology:

Case: https://kavyasamudrala.blogspot.com/2021/05/liver-abscess.html 

Review: https://shubankarkandukuri.blogspot.com/2021/05/general-medicine-assignment-may-2021_77.html 

This is a case of liver abscess. Given that the patient is a chronic alcoholic and heavy smoker , liver disease are likely. The culture report showed that he is infected with methicillin sensitive Staphylococcus aureus to which the treatment regimen was followed. The following hospital stay included antibiotic therapy and an advice for pigtail catheterization was given but later on it was found that the abscess was not drainable . The  symptoms were treated and medication was advised on discharge .The patient was treated to the best of available resources but a more permanent solution for the liver abscess should be found. High fat meals can precipitate severe symptoms in patients with liver abcesses and that should be considered. A more permanent solution would provide any future distress that maybe experienced by this patient.

6) Neurology

Review:

https://164sasiharshithjasthi.blogspot.com/2021/05/have-been-given-following-cases-to.html

Case :

https://amishajaiswal03eloggm.blogspot.com/2021/05/a-50-year-old-patient-with-cervical.html 

This is a case of cervical myelopathy presenting with weakness in all four limbs. He is a known case of hypertension and is on regular medication. After the necessary investigations were done, C3-C6 OPLL that is osteomalacial changes were seen and referred for neurosurgical intervention. Quadriparesis and hypokalemia were also seen. Finger escape sign was seen. Wartenberg's sign is a neurological sign consisting of involuntary abduction of the fifth (little) finger, caused by unopposed action of the extensor digiti minimi. . This finding of weak finger adduction in cervical myelopathy is also called the "finger escape sign"The required treatment inculding steroids , vitamin supplementation were given. Surgery was advised for a better routine life. The treatment of this patient was adequate along with long term option of surgical intervention gave the patient adequate solution.

7. Neurology 

Review : https://164sasiharshithjasthi.blogspot.com/2021/05/have-been-given-following-cases-to.html 

Case :

https://neerajareddysingur.blogspot.com/2021/05/general-medicine-case-discussion.html?m=1 

This is a case of cortical vein thrombosis with hemorrhagic venous  infarction in right posterior temporal lobe with and iron deficiency anemia. Required investigations were done and MRI confirmed cortical vein thrombosis to resolve that clexane was prescribed. Clexane ( enoxaparin) low molecular weight heparin binds and potentiates antithrombin III. Further , seizures were seen due to persisting excitable foci by abnormal firing of neurons. All required treatment was given and progress in the patients condition was seen. Neurological diseases are tricky and this patient was dealt with adequate care which resulted in this better health.

8. Pulmonology :

 Case :

https://54tejasreekandregula.blogspot.com/2021/06/70-year-old-male-with-fever.html 

Review : 

https://54tejasreekandregula.blogspot.com/2021/05/general-medicine-assignment.html 

This is a case of viral pneumonia secondary to COVID -19. Given the ongoing pandemic situation, this patient tested positive for COVID -19 and was admitted.

Further investigations revealed impaired CBP and respiratory exam was abnormal with vesicular sounds. Steroids were given along with additional O2 , nebuliation and antipyretics. Vitamins were also prescribed. And patient was subsequently discharged upon betterment. The SARS-Cov-2 virus has been rapidly spreading causing respiratory distress progressing to ARDS and proving fatal. The medical intervention for this patient was given before the symptoms worsened to an irreversible state and the patient got better. Appropriate treatment at the earliest is the best way to deal with the ongoing pandemic. Patient should be quarantined until he becomes negative for COVID-19.

9. Cardiology: 

Case :

https://preityarlagadda.blogspot.com/2021/05/biatrial-thrombus-in-52yr-old-male.html 

Review:

https://33manogna.blogspot.com/2021/05/general-medicine-assignment-for-month.html 

This is a case of atrial fibrillation and bilateral thrombus. The patient presented with shortness of breath, decreased urine output and anuria. Upon investigations, s.creatine and b.urea were elevated. 2 D echo showed dilated heart function with severe lv dysfunction. Renal function tests were also impaired. Cardio renal syndrome was suspected. Several symptoms were treated using appropriate medication and the patient's condition improved and he was discharged.Loss of Atrial contraction and Left atrial dilatation causes stasis of blood in the LA and may lead to Thrombus formation in the Left Atrial Appendage. This predisposes patients to stroke and other forms of systemic embolism. The patient was treated satisfactorily and his recovery will depend on his adherence to the medication which was given upon discharge.

10. Cardiology :

Case : https://daddalavineeshachowdary.blogspot.com/2021/05/67-year-old-patient-with-acute-coronary.html?m=1 

Review :

https://akash688.blogspot.com/2021/05/online-blended-bimonthly-assessmentmay.html 

This is a case of acute coronary syndrome in patient with DM and past history of TB. She presented with SOB and sweating.  ECG showed characteristics for an NSTEMI that are depressed ST wave , no progression of Q wave. Medication was given and a PCI was recommended. It is coronary angioplasty for treating cardiac diseases. The patient was sent home as the procedure was non emergent due to the ongoing pandemic. PCI was not performed. It is to be noted that patients with chronic diseases are highly susceptable to COVID -19 and if they contract the disease , it could prove fatal. Sending her home was a very practical decision but might have longtem repercussions for the patient if she were to contact COVID-19.

QUESTION 2 

https://pravallikagade41.blogspot.com/2021/07/55-yr-male-with-weakness-in-left-ulll.html

QUESTION 3

https://60shirisha.blogspot.com/2021/06/medicine-case-discussion_14.html?m=1 

This is a case of heart failure due to left ventricular dysfunction with affection fraction equal to or less than 40( HFrEF). Patient presented with distention of abdomen and shortness of breath. She is a K/C/O of hypothyroidism since 5 years and was on thyronorm 100mg OD. ECG showed atrial fibrillation.  Almost all her investigations were normal. She had low bp. Antiarrhythmics and anticoagulants were given but her biochem report showed severe hyperthyroidism may have caused her to have A-fib. As the defibrillation was being attempted , she passed away. I think this is a case of factitious hyperthyroidism. (https://medlineplus.gov/ency/article/000309.html ). Taking too much thyronorm for hypothyroidism could’ve caused hyperthyroidism in this patient which cause her fatal heart fibrillations. If her thyroid function tests were done earlier, appropriate medication could be given and she couldve been saved. 

QUESTION 4 

The diagnosis of HFrEF was made due to the ECG and 2 D echo results. 

ECG showed atrial fibrillation and 2 D echo showed Akinetic segment in LAD territory with EF 35%  and RVSP 100mmhg,B/L pleural effusion,mild pericardial effusion.

Antiarrhythmics and anticoagulants were given to help this condition and to prevent further fibrillations but as the underlying cause (factitious hyperthyroidism) was not resolved , fatal fibrillations returned.

All other routine investigations were done and most of them appeared normal. 

As the patient’s presenting symptoms indicated a cardiac condition ECG and 2D echo were done whose results proved to be very useful. 

The decision to put the patient on antiarrhythmics and anticoagulants was well reasoned. 

Performing thyroid function tests earlier could have been lifesaving as it would help treat the underlying cause.

QUESTION 5

In the last month , we began our clinical postings for the first time. Due to the ongoing pandemic, postings are taking place online which is making it slightly challenging for us to follow. Nevertheless, the online clinical postings have kept us interested in the day to day happenings of the hospital. They help us apply our subjective knowledge in a clinical setting which helps to form a bridge between both. Although the wards are extremely chaotic, professors and interns have been doing their best to pass on their knowledge to us and it is very encouraging for undergraduates to be present in a clinical setting. It helps us understand how much practical knowledge differs from reading books. We greatly appreciate the opportunity given to us and are trying to utilize it thoroughly. I have learnt several things starting from history taking to writing a case sheet. I also got to understand the grievances of patients and how important it is to provide a healing atmosphere for their recover. Our HOD of General Medicine, Dr. Rakesh Biswas has been explaining each and every single case along with the pathophysiology of symptoms and further complications. Discussions on the cases with my peers helped me understand multiple ways to go about relating the symptoms to different organ systems and in understanding the etiology of the diseases. Interactive learning is taking up a huge role in our academics and it will make me better part of a medical team. I thank our General medicine department for presenting us this great opportunity and helping me be better.