Bimonthly assessment august 2021

 BIMONTHLY EXAM AUGUST

1) REVIEW 

https://2018-21batchpgy3gmpracticals.blogspot.com/2021/08/18100006003-case-presentations.html?m=1

LONG CASE : 

A 44 year old man presented with a 3-day history of bilaterally symmetrical rapidly progressive generalized edema.

*evolution of symptomatology is well described in the illness .

* Proper past ,personal ,family ,surgical ,medical and immunization histories are provided.

* Differential diagnosis for the conditions he's been in are given . 

*classification criteria for rheumatoid arthritis is provided which gives us idea in which category patient is in based on points .

*The possible scenarios that can be are described in brief .

*Diagnostic approach is mentioned.

*After final diagnosis , further plan of treatment is given clearly.

SHORT CASE : 

A 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.

*Present illness is described very well with each and every detail explained properly. 

*All the histories and examinations done are mentioned .

* Problem presentation with treatment are provided.

*source for resting tremor is also given at the last.

SHORT CASE : 

19 year old male resident of Nalgonda and currently studying intermediate ,came to opd with complaints of :

-Itchy Ring leisons over arms ,abdomen ,thigh and groin since 1 and half year .

-Purple stretch marks all over abdomen ,lower back ,upper limbs ,thighs since 1 year .

-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 .

*Present illness with evolution of symptomology is perfectly described.

*Other histories with examinations done are given.

*Pictures provided clearly indicate it as a case of cushings syndrome . 

*They also explained ruling out endogenous cushings syndrome and giving a final diagnosis of iatrogenic . 

QUESTION 2

•Long case :

A 44 year old stonemason from Miriyalguda, presented with a 3 day history of anasarca, frothy urine and gradually decreasing urine output, on a background of a 10 year history of chronic bilaterally symmetric polyarthritis (evidenced by severe pain, edema and limitation of joint movements).

Diagnosis : 

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.

*Final diagnosis is being done after excluding factors as in differential diagnosis . And Taking into all the possible scenarios around it. 

Treatment

Free water restriction for Hyponatremia

Tab. PREDNISOLONE P/O 20 mg OD

Tab FEBUXOSTAT P/O 80 mg OD

Haemodialysis for worsening renal dysfunction

•Shortcase : A 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.

Diagnosis :

 6 months history of gradually progressive, asymmetric rest tremor with autonomic features is provisionally diagnosed with 

1. Idiopathic Parkinson's Disease Stage 1 with denovo HTN.

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

Treatment:

1. Tab. Syndopa Plus 125 mg QID

2. Tab. Syndopa 125 mg CR OD

3. Tab. Telma 40 mg OD

•Shortcase 2 : 

19 year old male resident of Nalgonda and currently studying intermediate ,came to opd with complaints of :

-Itchy Ring leisons over arms ,abdomen ,thigh and groin since 1 and half year .

-Purple stretch marks all over abdomen ,lower back ,upper limbs ,thighs since 1 year .

-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 .

Diagnosis : 

IATROGENIC CUSHINGS SYNDROME SECONDARY TO TOPICAL CLOBETASOL APPLICATION ALL OVER BODY FOR APPROXIMATELY ONE YEAR.

TINEA CORPORIS

DENOVO HTN . 

Treatment: 

Ointment AMLORFINE 

FUSIDIC ACID CREAM.

SALINE COMPRESS OVER LEISONS.

Plan to start anti fungals on next visit once dose of steroids is reduced .

TAB HIZONE 15 mg per day in three divided doses @ 8am ,12 pm and 4 pm.

Tab Shelcal 500 OD and Tab Vit D 3 Od.

Tab ULTRACET /PO/SOS.

QUESTION 3

LONGCASE : 

This is a case of acute glomerulopathy On Bilaterally symmetrical chronic progressive erosive peripheral polyarthritis .

Investigations done are : 

*X-ray AP view of the hands and wrists - Osteopenia and erosions of the MCP and PIP joints are noted. Scallop sign +. Significant soft tissue swelling is also noted.

*Chest X-ray PA view - Full inspiratory, underexposed film with no malrotation or angulation. Bones - Clavicle, Head of Humerus, Coracoid process and acromion of scapula appear normal. The ribs are normal. No mediastinal lymph nodes or enlargement. The right heart border shows mildly dilated right atrium. The left heart border shows a prominent aortic knuckle, the pulmonary bay area is normal, the left atrial appendage appears normal and the left ventricular free wall also appears normal. The bronchovascular markings are also prominent, likely due to underexposure.

*Urine Microscopy - Freshly voided urine sample was centrifuged at high speed (> 2700 RPM) and sediment collected and fixed on glass slide and examined under microscope at 400 (10x * 40x) showed DYSMORPHIC RBCs (black circles) and occasional pus cells (red circles). Dysmorphic RBCs were those that had altered shape, microcytic or with membrane defects.

Diagnostic approach for the case and investigations are well explained and are easily understood . 

Shortcase : This is a case of Parkinson's disease and multiple system atrophy .

All the general and systemic examinations are done and Reflexes examined .

Cranial nerve examination along with sensory and motor reflexes examined.

Co ordination tests , ECG and 2D echo are done .

Shortcase : This is a case of iatrogenic cushings syndrome due to Topical clobestasol application all over body . Along with Tinea corporis and Denovo HTN .

Investigations done are CBP CUE LFT RFT ECG 

USG ABDOMEN.

As he's also been suffering with Tinea corporis , ointments and cream , saline compress over area are recommended.

X ray spine was done on complaints of backache .

*in diagnostic dilemma whether endogenous CUSHINGS is also present in this patient , as he is responding slowly to treatment . 

* advised him to review after 15 days to see progress . And accordingly plan to evaluate further to rule out endogenous CUSHINGS SYNDROME.

QUESTION 4

1. 45f with metasttic breast cancer

2. 34f-headache-vomiting-

QUESTION 5 : 

Telemedicine favours long distance patient doctor relation ship where it increase the faith of patient in doctor and update doctor regarding their patient health and progression.

online logging improves transfer of patient related health status and investigations overseas in seconds.

there are few requesits should be followed 

1. taking consent for sharing health data

2. de-identify patient identifiers

3. proper documentation of series of events.