CASE-BASED LEARNING 2024

1/5/2024

Admissions under unit -1

1.A 47-year-old male, known to be diabetic, presented with fever, severe weight loss, and loss of appetite for one month. He has a previous history of pulmonary tuberculosis seven years ago, for which he underwent Anti-Tuberculosis Treatment (ATT) for six months. He also reported experiencing loose stools for the past ten days. Additionally, he complained of passing small amounts of stools during urination and weakness in all four limbs. Physical examination revealed normal vital signs, bronchovesicular breath sounds in both lung apices, and a non-tender soft abdomen. The neurological examination was found to be normal.

He had received treatment at other hospitals with antibiotics, but there was no improvement in the fever which persisted. The differential diagnoses considered included reactivation of pulmonary tuberculosis and Pott's spine (suggested by weakness and fecal incontinence). Further investigations revealed anemia, elevated ESR, and a creatinine level of 2.1 (renal TB was suspected). Fever profiles, including tests for dengue and malaria smears, were negative.

During hospital rounds, questions were raised regarding the potential causes of fecal incontinence. Rectal TB was considered as a differential diagnosis, and the role of proctoscopy in the evaluation of rectal TB was discussed due to the unavailability of colonoscopy or sigmoidoscopy. Spinal TB was also considered, prompting an examination of sacral sensations and anal tone.

The localization of fever was further investigated. Chest X-ray showed bilateral opacities and fibrotic changes as sequelae of previous infection, along with an enlarged right hilar lymph node. Blood and urine cultures were negative, and stool analysis was sent for evaluation. Despite not producing sputum, a referral to a pulmonologist was made, and a High-Resolution CT (HRCT) of the chest was planned.

Referrals were also made to a gastroenterologist due to concerns of disseminated TB. Investigations including a CT abdomen with oral contrast and colonoscopy were advised to rule out malignancy and intestinal TB given the patient's inconsistent history of melena, weight loss, and other symptoms.

Further imaging revealed left upper lobe cavities and bronchiectasis with patchy consolidations on HRCT of the chest, along with findings of a paravertebral collection from C4-D1 vertebral bodies, chronic pancreatitis, and a right renal space-occupying lesion incidentally detected. Subsequent bronchoscopy confirmed the presence of Mycobacterium tuberculosis with Rifampicin sensitivity (TrueNAAT positive).

An MRI of the cervical spine confirmed the diagnosis of Pott's spine. Anti-Tuberculosis Treatment (ATT) was initiated; however, the patient developed acute shortness of breath after returning home and required intubation. Unfortunately, the patient passed away later on, with the renal mass remaining uninvestigated

2. Middle-aged female with type 2 DM who had taken insulin and skipped meals was admitted with hypoglycemic seizures and was started on a 25% dextrose infusion and kept under monitoring.

Postgraduates were asked about the possible reasons for hypoglycemia in patients on insulin.

A brief review of the literature was done, and we concluded the possible reasons as:

- Insulin overdose

- Skipped meals

- Renal failure

- Liver dysfunction causing impaired glycogenolysis

- Infections and stress

3. Elderly female with acute CVA (right fronto-parietal infarct).

Importance of Swallowing assessment was explained to the post graduates 

4. An elderly male patient, who is a chronic smoker, was admitted with an acute exacerbation of COPD. Examination revealed diffuse wheezing, and he was managed with nebulizations and hydrocortisone.

Postgraduates were shown the clinical findings of COPD, and chest X-ray findings were discussed.

They were asked to calculate the CAT (COPD Assessment Test) score to plan further management based on GOLD guidelines.

Treatment options based on NICE guidelines were discussed. PFT was advised once the patient is stabilized.

This was followed by a brief discussion on cor pulmonale.

The postgraduates were also explained about smoking cessation counseling.

———-

Admissions under unit -1 

1.Pyelonephritis with negative urine culture

2.Lumbar spondylosis

3.Acute infective GE

4. Acalculous cholecystitis

5.BPPV

______________

Sunday duty rounds

Massive pleural effusion-lymphocytic predominant 

Post operative delirium on ventilator with hypertension 

CKD on MHD with fever and altered sensorium- Uremic encephalopathy + Septic encephalopathy

______________________________________________________________________

Sunday admissions under unit 4

65 year female with 3weeks history of fever and palpitations

Diagnosed with clinical malaria, AF with moderate MR and Heart failure

With pain abdomen ? acute mesentric ischemia

CT abdomen was normal and CT angiogram was not available

Patient was initiated on Heparin bridging with warfarin

She responded well and the pain abdomen subsided but interestingly despite optimal dose of heparin her APTT levels remained normal. However, her symptom of pain abdomen subsided and was discharged on warfarin due to her high CHAD2VASc score and is under follow-up.

36 year male with Status epilepticus, NCC with perilesional edema

Raised trop i,echo changes-Hypertensive heart disease.

Young onset hypertension 

_______________________________________________________________

Admissions on 21/5/2024 under unit 2

AIHA with thrombocytopenia (?Evan's syndrome) and high retic count.

LDH was increased, direct coomb's test was positive 

Patient was started on steroids and is under follow-up

Steroid resistant membranous glomerulopathy( serology based diagnosis)

Patient was resistant to 3 cycles of cyclophosphamide with steroid pulse and was not affordable for rituximab

He was initiated on mycophenolate mofetil and is kept under follow up.

—————

Referral from psychiatry:

The patient is a 36 year old male who was last seen by his wife in August 2023, after which he went to work as a lorry driver and went missing. The police could not find him. He traveled to many places in India (including Kasi) with some sadhus and ended up begging for food from his neighbor’s house in May 2024. He was seen by his in-laws and taken home.

The patient reports complete retrograde amnesia. He does not remember anything from childhood to October 2023, until he woke up lying in a train in Bhubaneswar without knowing how he got there.

Importantly, he is a chronic alcoholic.

He is not able to recall anything about his childhood or family, even if he is shown some photographs taken in the past

Chronic retrograde amnesia secondary to thiamine deficiency was suspected. 

---------------------------------

Admissions on 28/05/2024

1.60 year old female patient with hypertension presented to the OPD with sudden onset bilateral drooping of eye lids for the last 2 days , and the examination revealed bilateral complete ptosis with loss of adduction, superior and inferior eye movements in both eyes with divergent squint, down and out eye on right side with dilated fixed pupils on both sides. Bilateral acute onset 3rd nerve palsy was suspected and the differentials considered were: 

a. Midbrain stroke, b. Basilar artery thrombosis, c. Space occupying lesion in mid brain,

d. Miller-fischer-varient of GBS

Complete neurological examination and MRI brain was done which revealed a hyperacute mid brain infarct

2.A 53 year male presented with low grade fever for the last 2 months and high grade fever for 10 days. He was eventually diagnosed with chronic pancreatitis, pyelonephritis. The patient was managed with IV fluids maintaining adequate hydration and antibiotics. Urine and blood cultures were sent and CECT abdomen was planned

3.A 50 year female presented to the ER with excessive tiredness and body pains. On examination she had pallor and she was febrile. Her hemogram revealed pancytopenia with retic count suggestive of hypo-proliferative marrow. Peripheral smear was showing evidence of dimorphic anemia but her serum ferritin and B12 levels were within normal limits. The patient is planned for bone marrow biopsy.

4.A 26 year female with history of hypothyroidism and membranous nephropathy admitted with uncontrolled sugars (? steroid induced ?tacrolimus induced ). The patient after being diagnosed with membranous nephropathy used steroids but as she developed cushingoid features steroids were gradually tapered and stopped 15 days ago. She was also started on Tab. Tacrolimus, 30 days ago. On examination her abdominal striae appeared to have decreased compared to previous admission, however she has persistent pedal oedema. Her GRBS was HIGH and HbA1c was 8.1 and was switched to insulin mixtard. The possibility of steroid induced diabetes and tacrolimus induced hyperglycemia were considered.

5. A 60 year male with previous history of cerebrovascular attacks and medication incompliance, presented with sudden onset weakness of right upper and lower limb weakness for 1 day and diagnosed with acute infarct in left MCA territory. He was managed conservatively with anti-platelets and physiotherapy. After 1 day there improvement in the grade of power by 1 point.(3/5 to 4/5)