Skip to main content

Bimonthly general medicine assessment - July 2021

 Name: Pravallika Gade 

Roll No: 41 

SEMESTER: 3rd 

1) Peer review 

Reference link: https://aksharakruthi.blogspot.com/2021/07/bimonthly-blended-assessment-for-june.html 

Case review - She has analysed all the cases after reading both the case report and the assessment and has come to varied conclusions on the cases, their prognosis, their treatments and the post discharge care received by the patient. She has gone into great detail about the causes and the solutions for the majority of the cases but has fallen short of criticism and has not provided valuable input and feedback that will help the doctors writing these cases improve their methodology. He has gone into detail of the cases after they have come to the op but has missed the root causes which could have caused the cases in the first place. Overall Akshara has done very well and I have learnt a lot from her assessment. My fellow peer has done a very good job doing the assessment considering that we had no prior experience and I am confident that both him and I can do a lot better over the course of our medical education.

2) My case report:

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

3) and 4) Case reviews

  1. AKI & CKD :

  1. Case link: http://srinaini25.blogspot.com/2021/07/srinaini-roll-no-33-3rd-semester-this.html 

The given case is of a 75 year old man with chief complaints of lower back pain for 10 days along with oliguria, pedal edema, sob & involuntary movements of limbs since 10 days. Patient has a history of jaundice 3 years ago treated by plant based treatment. No known case of HTN, TB & DM. On general examination of CNS , slurred speech was seen with slightly reduced left upper and lower limb power with increased tone on lower leg. All reflexes were elicited. Severe anaemia is seen with increased blood urea and creatinine. 

Provisional diagnosis -  Acute kidney injury with chronic renal failure. Uremic encephalopathy  and uremia induced tremors

Complaints & problems  

  • Oliguria, burning micturition

  • Sob grade 4

  • Elevated serum creatinine & blood urea

  • Encephalopathy and tremors 

Solutions

  • IVF given - to induce maturation

  • Salt restricted

  • Bp regularly monitored

  • Diuretics given

  • Foleys catheter

  • Load on kidney reduced & patient is released on diuretics. Kidney will heal over time


  1. Patient with coma and renal failure  :

  1. Case link: https://ananyapulikandala106.blogspot.com/2021/06/a-35yr-old-female-elog.html 

This is a case of a 35 year old female with diabetes mellitus type 2 and SOB. Lower back pain since 5 days with abdominal and chest pain. At time of admission GRBS was 580mg/dl, back pain since one year and worsened upon administering non-prescription antibiotics. Patient was immediately intubated as they were gasping for air. SpO2 60% was recorded. Severe Metabolic acidosis seen. Patient was stabilised but still remains in a comatose state. gangrene Formed on thigh removed surgically.

Provisional diagnosis -  DKA coma and AKI due to diabetic nephropathy

Complaints and problems 

  • Fever and SOB

  • High blood sugar levels

  • Low blood pH

  • Patient is comatose 

  • Gangrene 

Solutions 

  • Regular ABG done and pH maintained 

  • SOB stabilised by intubation 

  • High Sugar levels maintained by 10 units of insulin

  • Gangrene treated by cutting off flesh and underlying muscle 

 

  1. Case link: https://pallavi191.blogspot.com/2021/06/gm-cases_30.html?m=1  

This is a case of a 52 year old with chief complaints of abdominal distension since 7 days. Patient asymptomatic till 2 years ago then non healing injury to foot. Diagnosed with DM type II and was started on GIMI M2. Patient was admitted 7 days ago and 5 days ago they experienced constipation and altered sleeping patterns. 

Diagnosis

  • INFECTIVE ENDOCARDITIS

  • WITH AV VEGETATIONS WITH MODERATE AS SEVERE AR

  • WITH AKI

  • WITH ?UREMIC ENCEPHALOPATHY ? SEPTIC ENCEPHALOPATHY

  • WITH ULCER OVER SOLE OF RIGHT LEG

  • WITH HYPOALBUMINEMIA ? ALCOHOLIC LIVER DISEASE

  • WITH ACUTE MULTIPLE INFARCTS IN BILATERAL CEREBRAL AND CEREBELLAR HEMISPHERES

Treatment given:

Day 1:

1. Inj. Monocef 1gm IV/BD

2. Inj. Vancomycin 500mg IV/BD in 100ml NS over 1hr

3. Proctoclysis enema

4. Inj. Pan 40 mg Iv/OD

5. Inj. Thiamine 200 mg in 100ml NS /BD

6. Inj. HAI 6U S/C TID

 

Day 2&3:

Same treatment followed

 

Day 4:

Same treatment followed except Inj. Monocef.

Inj. Augmentin 1.2 gm IV/TID

Tab. Ecosprin 150mg PO/HS/SOS

Tab. Clopidogrel 75mg PO/HS/SOS

Tab. Atorvas 20mg PO/HS/OD added

 

Advice at Discharge:

1. Inj. Vancomycin 500mg IV/BD in 100ml NS over 1hr

2. Inj. Pan 40 mg Iv/OD

3. Inj. Thiamine 200 mg in 100ml NS /BD

4. Inj. HAI 6U S/C TID

5. Inj. Augmentin 1.2 gm IV/TID

6. Tab. Ecosprin 150mg PO/HS/SOS

7. Tab. Clopidogrel 75mg PO/HS/SOS

8. Tab. Atorvas 20mg PO/HS/OD added

C) AKI :

  1. Case link: https://laharikantoju.blogspot.com/2021/07/58-year-old-male-patient-elog-lahari.html?m=1 

The given case is of a 58 year old male with chief complaints of lower abdomen pain since 1 week with burning maturation & oliguria. Fever & sob (grade 4) is also seen. Patient has use of NSAIDs for back pain & headache and has common bouts of blurred vision & blackouts. 13 years ago trauma to head and is a known case of hon but not under medical management. Regular alcohol intake is seen up to 3 times a week. During physical examination high bp seen (140/90 mm Hg ) and GRBS of 113mg% was seen, tenderness around suprapelvic with pain on the right flank seen. Pus in urine with negligence albumin but elevated levels of serum creatinine [5.9] & blood urea (129) are seen.

Provisional diagnosis given - AKI due to idiopathic causes. Causes suspected include DM2 but no history seen, right ventricular heart failure but physical exam normal. Therefore HTN suspected but the ultimate cause was not determined.

Complaints & problems

  • Oliguria, burning micturition

  • Sob grade 4

  • Hypertension - 140/90 mm Hg

  • Elevated serum creatinine & blood urea

Solutions

  • IVF given - to induce maturation

  • Salt restricted

  • Bp regularly monitored

  • Diuretics given

  • Foleys catheter

  • Load on kidney reduced & patient is released on diuretics. Kidney will heal over time

 

D) CKD :

 

  1. Case link: https://krupalatha54.blogspot.com/2021/07/a-49-yr-old-female-with-generalized.html?m=1 

 

This is a case of a 49 year old female who had a mass 13 years ago with bleeding and was operated for hemorrhoids. Has been on NSAIDs for the past 3 years for muscle aches. Has had 20 days of fever and general weakness. Has been vomiting for 3 days. No SOB seen and urine output is normal. No significance seen in personal history. Physical examination shows  restricted right and left knee joint movement and very deep pallor. Complete blood profile shows Dimorphic anaemia is seen along with very low RBC count. Bilirubin elevated but conjugated bilirubin normal therefore excess breakdown of RBC is seen. LFTs are normal. Hence RBC formation is suspected and Bone Marrow biopsy is aspirated

Provisional diagnosis - Multiple myeloma (plasmacytosis 70%)

Complaints and Problems 

  • Fever and General weakness

  • Severe and dimorphic Anaemia

  • Jaundice 

Solutions 

  • Erythropoietin injections are prescribed twice a week for the anaemia.   

  • Referred to higher centre

This is an interesting case because the symptoms do not coincide with the classical presentations of Multiple myeloma. This is also seen in the other case seen by Dr Rakesh Biswas in 2009 where a 47 year old with lower back pain presented to the OP. Even after multiple ways to find the source of acute renal failure the cause could not be found. Finally after a month a CT and a bone biopsy showed the presence of multiple myeloma. This case helps us learn about multiple methods of presentation of the same disease.

Link to case by Dr. Rakesh Biswas :  https://casereports.bmj.com/content/2009/bcr.03.2009.1726#article-bottom    

E) Patients with acute on CKD :

a) Case link: https://kavyasamudrala.blogspot.com/2021/05/medicine-case-discussion-this-is-online.html?m=1 

This is a case of a 52 year old man with diabetes mellitus type 2, 3 months of burning micturition with no association of fever, He was diagnosed with Prostatomegaly (60gm) and advised TURP. Underwent TURP. Returned to hospital with complaints of excessive drowsiness and excess sleep. On the third admission  there was high grade fever and burning micturation since 4 days. Creatinine levels 10mg/dl. Normalised and discharged. Finally admitted again with High grade fever and pus in urine. General examination revealed very low haemoglobin with anaemia and elevated serum creatinine. Blood urea was also slightly elevated with a drop in levels of sodium. 

 

Probable diagnosis - Renal AKI with urosepsis and DM since 5 years and Diabetic nephropathy with anaemia due to CKD

Complaints and problems 

  • Fever and Burning urine 

  • Pus in urine 

  • Prostatomegaly 

  • Elevated blood sugars 

Solutions 

  • Antibiotics for Prostatomegaly and pus in urine 

  • TURP procedure for Prostatomegaly 

  • Diuretics for oliguria and burning urine 

  • Huminsulin for elevated blood sugars 

 

  1. Case link: https://rishikakolotimedlog.blogspot.com/2021/07/45-year-old-male-with-chief-complains.html?m=1 

This is a case of a 48 year old man with acute shortness of breath worsening from Grade 2 to 3 to 4 from the past 4 days. 2 years back he was diagnosed with Chronic renal failure and was given symptomatic treatment for the same. 7 months ago the patient had chest pain with heart failure and after an angiogram he felt wrong. SOB over the course of 2 months increased in grade over the course of last week. On general examination pedal oedema, dyspnoea present but wheezing absent. No abnormalities seen in CNS examination with 15/15 on the Glasgow scale. FBS and PLBS elevated, Complete blood picture showed low HB. 

Provisional diagnosis - HFrEF reduced ejection fraction secondary to CAD and CRF

Complaints and problems 

  • Shortness of breath

Solutions

  • Beta blockers given to help with the congestive heart failure and elevates the shortness of breath.

 

  1. Case link: https://krupalatha54.blogspot.com/2021/06/this-is-online-e-log-book-to-discuss.html?m=1 

This is a case of a 60 year old female with SOB and Anasarca. She has had oliguria for the past 3 days. Vomiting and loose stools 5 days ago and subsided. History of SOB since 15 years and 10 to 15 episodes a year. 2 months ago pneumonitis with type 1 respiratory failure. On examination elevated blood Urea is seen along with Serum creatinine. SpO2 reduced to 80% in room air.

Provisional diagnosis - Left ventricular failure causing reduced ejection fraction secondary to CRF 

Complaints and problems 

  • Shortness of breath

Solutions

  • Beta blockers given to help with the congestive heart failure and elevates the Shortness of breath

F)Patients with AKI :

  1. Case link: https://keerthireddy42.blogspot.com/2021/07/43-yr-old-male-of-nalgonda-came-to.html?m=1 

This is a case of a 43 year old male with complaints of loose stools for 20 days and pedal edema with abdominal distension. Chronic alcohol intake is seen and history of jaundice, 2 years ago. Pallor is seen but icterus is absent.

 Provisional diagnosis-  

  • ALCOHOLIC HEPATITIS ,

  • AKI SECONDARY TO ACUTE GASTROENTERITIS  

  • HFrEF SECONDARY TO CAD 

  • ALCOHOLIC AND TOBACCO DEPENDENCE SYNDROME

Complaints and problems 

  • Pedal edema 

  • Abdominal distension 

  • Jaundice 

Solutions 

  • Diuretics given for pedal edema.

  • For jaundice the patient was asked to stop alcohol and thiamine injection was given.

 

  1. Case link: https://casescape.blogspot.com/2021/06/acute-kidney-injury-secondary-to.html?m=1 

This is a case of a 60 year old with chief complaints of pedal edema since 10 days with high grade fever and oliguria. The patient was diagnosed with DM2 5 years ago. In 2019 she was diagnosed with AKI and secondary urosepsis and resolved with dialysis. Burning micturition seen along with oliguria. Occasional alcohol consumption. Pallor is seen but no icterus. High BP is seen with 170/110 mm Hg. 

Provisional diagnosis: Acute kidney injury secondary to urosepsis with hyperkalemia and anaemia 

Complaints and problems 

  • Acute kidney injury with urosepsis and burning micturition

  • Hyperkalemia

  • Anaemia 

  • Hypertension 

Solutions 

  • Iv fluids and diuretics given for AKI and urosepsis 

  • NSAIDs for pain 

  • Anti hypertensives 

 

  1. Case link: http://chavvaclassworkdecjan.blogspot.com/2021/06/pancreatitis-in-chronic-alcoholic-with.html?m=1

This is a case of a 31 year old male with abdominal pain since 1 week, epigastric pain, non radiating and relieved upon sitting. Bilious vomiting since one week. Complains of SOB since 2 days. Patient hospitalised one week ago. Creatinine elevated to 7.6 after admission. Hard liquor since 4 years, regularly. Last intake of 360 ml one week ago. Chewing tobacco since 10 years. BP elevated. Sp o2 88% in normal air. GRBS normal. Slight tremors seen. Distension of abdomen seen with epigastric and hypogastric tenderness. 

Provisional diagnosis - Acute pancreatitis with associated AKI. Patient in alcohol withdrawal. 

Complains and problems 

  • Bilious vomiting 

  • SOB 

  • Creatinine elevated to 7.6

  • Alcohol withdrawal 

  • Elevated BP 

  • Sp O2 

Solutions 

  • I/O charting for AKI

  • Hemodialysis for AKI 

  • CECT abdomen was done

Case is still ongoing and the case log will be updated when further treatment is given.

5) Review on my online posting experience:

Since our 3rd semester began, we have been attending online postings. They have been informational in spite of all the technical issues. The general medicine department has shown a great deal of interest in our academic progress and has made sure that all of us remain in the loop throughout the process. We are indeed very lucky to have such a great set of faculty teaching us and we plan to take full advantage of the opportunity provided to us. The assessments , case reports and constant insight into the working of the department at the hospital through a message dialogue has kept us informed and is giving us a great deal of insight into the routine patient roster. We have been maintaining our own blogs to record our progress through this process. Overall I would say that we are benefitting from this program and we are looking forward to being there in person to learn in the near future. I thank Dr. Rakesh Biswas for this opportunity.

 

 

 

 

 

 

 








Comments

Popular posts from this blog

A 25 yr old female with fever since 3 days

  Name: G.Pravallika   Roll no 41 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 a series of inputs from an available global online community of experts with an aim to solve those patients' clinical problems with collective current best evidence based input. The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitted.  Date of admission: 28/11/23 A 25 yr old female with the chief complaints of  ℅ fever since 3 days ℅ passage of loose stools since morning-3 episodes  ℅ vomitings since morning History of presenting illness: Pt was apparently asymptomatic 3 days ago then she developed fever insidious in onset, gradually progressive high grade. No aggravating or relieving factors. Then

BIMONTHLY GENERAL MEDICINE ASSESSMENT FOR THE MONTH OF AUGUST 2021

PRAVALLIKA GADE , ROLL NO 41  3rd semester. QUESTIONS:  https://medicinedepartment.blogspot.com/2021/08/medicine-paper-for-aug-2021-bimonthly.html?m=1    QUESTION 1: LONG CASE:   This is primarily a case of Acute glomerulonephritis, likely due to Secondary Amyloidosis due to Chronic Poorly Treated Seronegative Erosive Rheumatoid Arthritis . The patient presented with bilateral, symmetric, pitting type of edema which was extending upto the middle of his leg. The patient also had chronic pain in the joints leading to restriction of movement since 2011. Upon previous hospital visits, the RA factor was negative. Therefore, the patient was prescribed analgesics and sent home. Chronic use of analgesic drugs was seen from 2011-2019, the details of which were undocumented. Hyperuricemia was also observed in one of his recent visits during last year and Febuxostat was prescribed as it has proven to be more effective than Allopurinol in recent studies. Anasarca was the chief complaint of this vi

A 35 YEAR OLD FEMALE PATIENT WITH FEVER AND THROMBOCYTOPENIA - DENGUE

  A 35 YEAR OLD FEMALE WITH FEVER AND THROMBOCYTOPENIA   This is an online e log book to discuss our patients' deidentified health data shared after taking his/ her/ guardians consent. Here we discuss our individual patients' problems through a series of  inputs from an available global online community of experts with an aim to solve those patients' clinical problems with the collective current best evidence based inputs. This e- log also reflects a patient centered learning portfolio.     NAME : G PRAVALLIKA ROLL NO: 41 3RD SEMESTER    A 35 years old woman presented to the casuality with chief complaints of fever, cold , vomiting and cough.   HISTORY OF PRESENT ILLNESS :   A 35 year old woman presented to the casuality with chief complaints of  fever since 1 week, cough since 1 week and vomiting since that morning on 17/10/21. She has been having low grade , intermittent fever with no diurnal variation and non productive cough. She also had 3 episodes of non projectile, n