BIMONTHLY BLENDED ASSESSMENT - AUGUST 2021

 This is Varshini reddy of roll no.25 from third semester 

The following blog is an assignment that was given to us.

Question link: https://medicinedepartment.blogspot.com/2021/08/medicine-paper-for-aug-2021-bimonthly.html?m=1

Question 1: Please go through the long and short cases from this link: https://2018-21batchpgy3gmpracticals.blogspot.com/2021/08/18100006003-case-presentations.html?m=1 and provide your critical appraisal of the captured data in terms of completeness, correctness and ability to provide useful leads to analyze the diagnostic and therapeutic uncertainties around the cases shared and  share your thoughts around each answer by the student along with your qualitative insights into what was good or bad about the answer. 

Answer:

Long case: It is a case of 44 year old male, who presented with a 3-day history of anasarca and decreased urine output.

In terms of completeness, the case study was explained in a detailed manner and the history that was taken, examinations and investigations that were done, the final diagnosis and the treatment that was given everything was included and they were explained in a chronological order in detail and are complete. 

In terms of correctness, the data was given correctly.

The diagnostic approach that was done in this case study was commendable, it included certain reviews of literature related to this case study, different case scenarios were considered and the patient has Bilaterally Symmetrical Chronic Progressive Erosive Peripheral Polyarthritis, for this condition, differential diagnosis was also considered for concluding the final diagnosis.

Final Diagnosis that was concluded includes- Acute Glomerulonephritis, likely due to Secondary Amyloidosis due to Chronic Poorly Treated Seronegative Erosive Rheumatoid Arthritis.

Dilutional Hyponatremia secondary to Anasarca due to Glomerulonephritis

Hyperuricemia likely due to decreased Uric Acid Excretion Precipitating Gouty Arthritis

Anemia of Chronic Disease secondary to Poorly Treated Rheumatoid Arthritis.

The questions that were answered after the case study were based on different reviews and clinical trials. I think the answering to the questions was good and understandable and all the questions were answered.

Short case 1 : It is a case of 49 year old English and Telugu language lecturer presented with a 2 month history of progressive asymmetric involuntary movements of his right index and middle fingers.

In terms of completeness, the case study was complete with all the required information( chief complaints, history of present illness, past history, medical history, personal history, family history, general examination, systemic examination, investigations, diagnosis and treatment). The symptomatology was mentioned in a chronological order and the case study was explained in a detailed way. 

In terms of correctness, the data was given correctly.

The diagnosis was concluded based on the symptomatology, examinations and investigations that were done.

The final diagnosis of this case study- a middle aged man presenting with a 6 months history of gradually progressive, asymmetric rest tremor with autonomic features is provisionally diagnosed with  

Idiopathic Parkinson's Disease Stage 1 with denovo HTN and 

Multiple System Atrophy - Parkinsonian Type (MSA-P).

Short case 2 : It is a case of 19 year old male resident of nalgonda with tinea corporis and Iatrogenic cushings syndrome. 

In terms of completeness, the case study was complete with all the required information. History was explained in an elaborated manner, everything was inlcuded, previous treatment history and his consultation with different doctors about his condition were also mentioned.  

In terms of correctness, the data was given correctly.

The provisional diagnosis that was concluded based on the symptoms, examinations and investigations was Iatrogenic cushings syndrome, Tinea corporis, Denovo HTN. After the first follow up, patient was symptomatically better and the Psychiatry opinion was taken and he was diagnosed with moderate depression . After the second follow up, patient complained of increased striae, as his lesions didn't subside dose of hizone was reduced to 7.5 mg per day, to see response.

At this point of time, there was diagnostic dilemma whether endogenous CUSHINGS is also present in this patient , as he is responding slowly to the treatment. He was advised to come for the review after 15 days to see progress . And accordingly plan to evaluate further to rule out endogenous CUSHINGS SYNDROME.

Final diagnosis of this case study was Iatrogenic cushings syndrome secondary to topical clobetasol application all over the body for approximately one year, Tinea corporis, denovo HTN.

Question 2 and Question 3: Please analyze the above linked long and short cases patient data by first preparing a problem list for each patient in order of perceived priority (based on the shared data) and then discuss the diagnostic and therapeutic uncertainty around solving those problems.

Include the review of literature around sensitivity and specificity of the diagnostic interventions mentioned and same around efficacy of the therapeutic interventions mentioned for each patient. 

Answer: 

Long case: It is a case of 44 year old male, who presented with a 3-day history of anasarca and decreased urine output.

• The problem list  includes: The patient was having chief complaints of 3-day history of bilaterally symmetrical rapidly progressive generalized edema.
• He was also having frothing of urine but no hematuria with gradually decreased urine output over the past 3 days.
• Prior to this, the patient reported that since 2011, he 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. 
• There were other activities also which were painful and difficult for the patient , those were holding his cup of tea or glass of water, Pain in his finger joints and wrist while brushing, Pain while holding mug when taking bath and Pain in toes and ankles on both sides when walking.
• The patient also had 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.
• Between the years 2011 to 2019, the symptoms that he had gradually progressed in severity, now also involving several large joints (shoulders, elbows, knees and hips) warranting several medical consults, where he was frequently prescribed pain killers.
• He also reported for the past 1 year, he developed subcutaneous swellings in the proximal joints of his fingers. He also had involuntary weight loss and loss of appetite.
• The patient also reported that, for the past 3 days, he has burning sensation in his eyes with increased tearing but no visual deficits.
• He also had Bilateral, purplish reticular markings on the sclera of both eyes. Palpebral conjunctival pallor and Bilateral Periorbital puffiness were present.
• He had leukonychia and bilateral pitting type pedal edema was present which was extending upto middle of legs.
• On examination he had problems of swelling, erythema, mild pain and limitation of active and passive movements in different parts of axial and appendicular skeleton.

The investigations that were done are X-ray AP view of the hands and wrists from which Osteopenia and erosions of the MCP and PIP joints, significant soft tissue swelling were noted. Scallop sign was present. 

From the chest X-ray PA view- The right heart border shows mildly dilated right atrium, left heart border shows prominent aortic knuckle.

Urine microscopy showed dysmorphic RBCs and occasional pus cells. 

The diagnostic approach of the case study- Acute glomerulopathy with bilaterally symmetric chronic progressive erosive peripheral polyarthritis. The features that are supporting the glomerulonephritis were  - Secondary Hypertension

- Oliguria (360 ml urine in the last 24 hours)

- Hypoalbuminemia (Serum Albumin 2.5g/dl) and Anasarca

- Dysmorphic RBCs in Urine

A review of literature that was done to evaluate the sensitivity and specificity of dysmorphic RBCs for glomerular disease pathologies -

1. One study conducted in Bangladesh showed that urinary dysmorphic RBCs were 92.7% sensitive and 100% specific for a biopsy confirmed diagnosis of glomerulonephritis.

2.Similar values of sensitivity and specificity was also confirmed in another study jointly conducted in Australia and China, where glomerulonephritis was confirmed with renal biopsy.

Thus, with glomerular disease being most likely, an anatomical diagnosis is made. The etiological cause for glomerular injury needs to be ascertained.

A careful construction of the problem representation for this patient and insight into the sequence of his life events can provide clues that the current acute problem could be a sequelae of his long term, poorly treated chronic problem.

Thus, a good clinical diagnosis of his musculo-skeletal problems is required to get a better picture of his current illness.

As the patient has Bilaterally Symmetrical Chronic Progressive Erosive Peripheral Polyarthritis. Differential diagnosis for such conditions include - 

Rheumatoid Arthritis (most likely)

Rheumatoid Arthritis with coexistent Gout

Psoriatic Arthritis

Enteropathic Arthritis

Reactive Arthritis

SLE

Polymyositis / MCTD (Mixed Connective Tissue Disorder) (least likely)

The patient has more than 10 joints involved with multiple small joints involvement, duration of symptom- 10 years, RA Factor - NEGATIVE; CRP elevated & ESR - 120 mm/hr . 

From ACR/EULAR classification criteria, a diagnosis of Rheumatoid arthritis is more likely. A review of literature showed that sensitivity of RA factor for Rheumatoid Arthritis was 28% and specificity was 87%.

For non RA rheumatological disorders, the sensitivity was 29% and the specificity was 88%. 

Thus, the authors concluded that (due to high specificity and NPV), the test is best ordered when the suspicion for a rheumatological is low but just high enough, that a negative result would increase the post-test probability of a rheumatological disorder being unlikely.

As this patient had a chronic history of symmetric small joint and then large joint inflammatory peripheral polyarthritis, With minor erosions notable in the PIP and MCP joints of both hands, classification criteria are diagnostic for Rheumatoid Arthritis.

As there is absence of muscle weakness, muscle pain and the presence of destructive arthritis makes the diagnosis of Polymyositis / MCTD extremely unlikely.

So there can be acute glomerulonephritis with chronic poorly treated rheumatoid arthritis. 

Final Diagnosis would be- 

Acute Glomerulonephritis, likely due to Secondary Amyloidosis due to Chronic Poorly Treated Seronegative Erosive Rheumatoid Arthritis.

Dilutional Hyponatremia secondary to Anasarca due to Glomerulonephritis

Hyperuricemia likely due to decreased Uric Acid Excretion Precipitating Gouty Arthritis

Anemia of Chronic Disease secondary to Poorly Treated Rheumatoid Arthritis.

Treatment that was given to this patient- 

Free water restriction for Hyponatremia

Tab. PREDNISOLONE P/O 20 mg OD

Tab FEBUXOSTAT P/O 80 mg OD

Haemodialysis for worsening renal dysfunction.

Short case 1: It is a case of 49 year old English and Telugu language lecturer presented with a 2 month history of progressive asymmetric involuntary movements of his right index and middle fingers.

• The problem list includes: The patient was having chief complaints of progressive asymmetric involuntary movements of his right index and middle fingers.
• He first noticed them happening nearly 6 months ago, which was very small in amplitude, affecting these two fingers only. He says that these movements often worsened with rest and abated with activity.
• He describes these movements as involuntary, rhythmic to and fro oscillations.
• The patient also had stiffness in his wrists (Right>Left), which has now ascended to his elbows. The stiffness was present throughout the range of motion. He also says that since the last 1 month, the same involuntary movements also started appearing in his left hand. 
• He also had difficulty in walking and walks with small, short steps and a forward stoop. 
• The patient also had difficulty in taking stairs up, he also feels that he sometimes might lose balance.
• He hasn't been having morning erections since 2 months and also reports a loss of sexual desire. He also says that since 2 months his bowel habits have been incredibly erratic, in that he sometimes has an immediate urge to defecate when he has tea and sometimes goes 2 to 3 days with constipation. 
• He has also been speaking in a monotonous drab since 2 months. 
• On examination there was hypertonia(cog wheel rigidity) in his right wrist.
• There were involuntary movements like resting tremors of right upper limb with high amplitude. From gait, it was noted that there was reduced arm swing.
• Micrographia was present.
• Postural hypotension and erectile dysfunction were present.

From the investigations that were done- ECG shows Sinus Tachycardia with pseudo infarct pattern in leads I and aVL with dagger q waves in the same leads.

2D echo shows Grade II diastolic dysfunction.

The diagnosis in this case study-  

Idiopathic Parkinson's Disease Stage 1 with denovo HTN.

Multiple System Atrophy - Parkinsonian Type (MSA-P).

Prognosis of Stage 1: 

Stage 1 is the mildest form of Parkinson’s. At this stage, there may be symptoms, but they’re not severe enough to interfere with daily tasks and overall lifestyle. In fact, the symptoms are so minimal at this stage that they’re often missed. But family and friends may notice changes in your posture, walk, or facial expressions.

A distinct symptom of stage 1 Parkinson’s is that tremors and other difficulties in movement are generally exclusive to one side of the body. Prescribed medications can work effectively to minimize and reduce symptoms at this stage.

Treatment that was given to this patient:

Tab. Syndopa Plus 125 mg QID to treat symptoms like tremors and slowness of movement. 

Tab. Syndopa 125 mg CR OD

Tab. Telma 40 mg OD

Short case 2: It is a case of 19 year old male with Iatrogenic cushings syndrome and tinea corporis.

• The problem list includes: The patient came with chief complaints of 
• Itchy Ring leisons over arms ,abdomen ,thigh and groin since 1 and half year for which he used auyurvedic medications for 1-2 months. 
• Purple stretch marks all over abdomen ,lower back ,upper limbs ,thighs since 1 year for which he used auyurvedic oils over the lesion. He also used clobetasol ointment over the leisons(for approximately 1 year all over the body) 
•  Abdominal distension and facial puffiness since 6 months.
•  Pedal edema since 3 months.
•  Low back ache since 3 months .
•  Feeling low , not feeling to talk to anyone.
• Weight gain and decreased libido since 3months.
•  Loss of libido and erectile dysfunction since 2 months
• The patient is also allergic to eggs, brinjal 
• On examination pedal edema was present which is of pitting type extending upto knee
• Abdominal distension, moon face were present.
• Pink striae was also noted over anterior abdominal wall, on lower back and on upper arms and thighs. Thin skin was also present .
• Poor healing was noticed over leg ulcers and easy bruising was also noted.
• Acne were present over the face and acanthosis nigricans was noted over the neck.
• Gynecomastia, Buffalo hump, sparse scalp hair were present.
• On skin examination- Multiple itchy erythematous annular leisons were noted all over abdomen, upper limb ,groin and inner thigh region .
• Multiple hyperpigmented plaques were also noted over bilateral lower limbs .
• Difficulty in getting up from chair is also noted.

The investigations that were done are CBP, TLC, PLT, CUE- from which albumin is +1, Pus cells 3-4, LFT, RFT, Albumin, Serum creatinine, Electrolytes and from ECG- sinus tachycardia was seen, LVH was also present.

The provisional diagnosis of this case report was Iatrogenic cushings syndrome, Tinea corporis, Denovo HTN.

For Tinea corporis, dermatologist opinion was taken and the advice that was given- Ointment AMLORFINE, Fusidic acid cream, Saline compress over lesions.

Patient was advised to get fasting  8am serum cortisol levels and was planned to start on low dose steroids to avoid adrenal crisis.

ACTH stimulation test was done and it indicated that there was HPA AXIS suppression and patient was started on TAB HIZONE 15 mg per day in three divided doses

Patient was advised to follow up after one month. After 1st follow up, Patient was symptomatically better, striae were palein color, pedal edema subsided. The dose of tab hizone was reduced.

For the low back pain the patient was advised with shelcal and vit. D3.

From the pyschiatric opinion, he was having moderate depression.

 

When the patient came for the second follow up he had complaints of excoriation over striae and appearance of erythematous macules over abdomen whenever he takes food he is allergic to. For which the dermatologist has advised Tab Itraconazole,lulifin cream and tab levocitrixin. 

Patients lesions didn't subside, and the dose of hizone was reduced to see the response.

At this point of time, there was diagnostic dilemma whether endogenous CUSHINGS is also present in this patient , as he is responding slowly to the treatment. He was advised to come for the review after 15 days to see progress . And accordingly plan to evaluate further to rule out endogenous CUSHINGS SYNDROME.

Final diagnosis of this case study- 

Iatrogenic cushings syndrome secondary to topical clobetasol application all over the body for approximately one year, Tinea corporis, denovo HTN.

Question 4: Share the link to your own case report this month of a patient that you connected with and engaged while capturing his her sequential life events before and after the illness and clinical and investigational images along with your discussion of that case. 

Answer:

https://varshinireddychada.blogspot.com/2021/08/general-medicine-e-log_14.html

It is a case of 24 year old female with Viral pyrexia secondary to thrombocytopenia.

The patient came to the opd with the chief complaints of fever, vomitings and bloating since 3 days. The fever was associated with chills and rigor( which was subsided on taking medication), it was also present throughout the day which was of intermittent type with no diurnal variation.

She had complaints of bloating followed by vomitings ( 3 episodes in a day) which had food particles as content.

On Examination, the patient was conscious and pallor was present. Tenderness of abdomen was also present in the right hypochondriac region. There was no focal neurological defect.

The Investigations that were done are Chest X-ray, ECG, DENGUE NS1 Antigen, IgG and IgM( Rapid test), Hemogram, Blood parasites(M.P.), Ultrasound.

From the investigations-

 Haemoglobin: 11.2gm/dl

 Platelet count: 80,000/cells/cumm

 TLC : 8,110cells/cumm 

From the Symptoms, Examination and Investigations, the Provisional Diagnosis that was concluded- VIRAL PYREXIA WITH THROMBOCYTOPENIA.

Treatment that was given to the patient-

Treatment on Day 1:

1. IVF  20NS 100ml/hr

           20RL 100ml/hr

2. Inj. PAN 40mg IV/OD

3. Inj. ZOFER 4mg IV/STAT- for treating nausea and vomiting. 

4. Inj. OPTINEURON 1 ampule

                1hr 100ml NS/IU/OD

5. BP/PR/RR/SpO2 CHARTING 4th hrly

6. STRICT I/O CHARTING

Treatment on Day 2:

1. Plenty of oral fluids

2. Inj. 10NS 75ml/hr 

          10RL 75ml/hr

3. Tab Pantop 40mg/PO/OD

4. Tab MVT/PO/OD

5. Strict I/O Charting 

6. BP/PR/SpO2 Charting 4th hrly

7. GRBS Charting 2th hrly 

Question 5 : Reflective logging  of one's own experiences is a vital tool toward competency development in medical education and research. 

Answer:

From the last 2 months of our third semester, we had classes on clinical subjects, which we attended from our homes through online lectures. Because of the pandemic, we didn't get a chance to attend clinical postings at the hospital. Starting from this month, we had offline classes, so we went to the college to attend our practicals and clinical postings. 

We got a chance to visit the hospital and take all the information that is required directly from the patient to make an E-LOG of a case. This was the first time that I took all the related information like chief complaints, history of present illness, past history, treatment history, personal history and family history directly from the patient. 

It was a great experience, even though I was sacred a little bit about how I would manage  collecting all the information that is required without making the patient uncomfortable. In this whole process, our intern has guided me on how to interact with the patient. Though the patient was not in a state to tell about complaints and history, we got all the information from the patients guardian who was very co-operative in giving us all the information that we required. 

I thank Rakesh biswas sir for giving us such opportunity of interacting with patient and make us do an E-LOG for our better understanding. This month has been great as we got to attend the hospital in person and by this our learning experience has improved.

I am looking forward for such a great learning experiences in the future. 

                                 - THANK YOU -