Wednesday, April 28, 2021

General medicine final practical short case

 April 28,2021

Short case - GENERAL MEDICINE 

"This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. 


Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. 


This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome."

 SHORT CASE

 45 year old male, resident of  ramanapet, farmer by occupation, came to the Opd, with chief complaints of 

shortness of breath since one year.

Bilateral pedal edema since three months.


 HISTORY OF PRESENT ILLNESS:


The patient was apparently asymptomatic one year back then he developed, shortness of breath, which was insidious in onset gradually progressive from grade two to grade four, aggravated on lying down and on exertion and relieved medications.

The patient also complains of pedal edema since 3 months, insidious in onset, gradually progressive from involving the ankle to involving the whole limbs, pitting type,  aggravated by walking , slight in the morning and more by the end of the day which relieved on elevating the legs. 

Patient also gives a history of decreased urine output since 1 month, insidious onset,  gradually progressive.

There's history of weight loss.

No h/o paroxysomal nocturnal dyspnea.

No history of cough and expectoration, chest pain, no history of palpitations and syncope .No history of fever, sore throat, joint pains. No hemoptysis, hematemesis, no history of Jaundice, no history of burning micturition.


PAST HISTORY:

He had a road traffic accident 3 years back, had a surgery on right leg and was on medications for one year (analgesics).

He is a known case of hypertension since 2 years, diagnosed when he went to a camp- was using nicardia 20 MG thrice daily and stop taking tablets since one year.

The patient is on dialysis since 10 months.

He is not a known case of diabetes, TB asthma, epilepsy.


PERSONAL HISTORY:

He has a mixed diet.

Appetite- normal

Sleep- disturbed 

Bladder- irregular

Bowel movements- regular

Addictions- chronic alcoholic for 20 years stopped drinking since last three years.


FAMILY HISTORY:

There is no significant family history.


DRUG HISTORY:

The patient used analgesics for a year.

 Used nicardia 20 MG for Hypertension.


GENERAL EXAMINATION:

The patient is conscious, coherent, Cooperative, moderately built and nourished.

Pallor - present

There are no signs of icterus, cyanosis, koilonychia, clubbing and lymph adenopathy.

Edema- present.

JVP- raised.




A-V fistula- felt













VITALS:

PR- 82bpm,regular,normal volume
BP- 130/80mm Hg right arm, sitting position
RR- 24cpm
TEMP- afebrile.

Local examination of cardiovascular system


Trachea appears to be Central 

Shape of the chest - normal

Apical impulse visible, appears to be shifted from its normal





no visible scars, sinuses, dilated veins in any part of the thorax, no bony abnormalities.

Palpation:

All Inspectory findings are confirmed.

Trachea is central confirmed by 3-finger test.

Apex beat is shifted outwards and downwards, 4 to 5 cm lateral to mid clavicular line in 6th intercoastal space.

no palpable heart sounds and no palpable murmurs. 

Percussion:

Right heart border shifted 1 cm right  from the right sternal border.
Left heart border shifted 4 to 5 cm lateral to midclavicular line.

Auscultation:

S1 S2- heard

No murmurs.

Per Abdomen:

Inspection-

Abdomen- distended 

Umbilicus -Central in position and slit like

flanks are full

no sinuses, scars or visible pulsations 

hernial orifices are free.


Palpation 






no local rise in temperature 

no tenderness  

no guarding and rigidity 

no palpable masses.


Percussion:

shifting dullness- present

liver span-normal


Auscultation:

bowel sounds are heard.


Respiratory system :

bilateral air entry- present

normal vesicular breath sounds heard 

basal crepitations present in both the lung fields.


Central nervous system- normal.


INVESTIGATIONS:

CBP- 

Hemoglobin- reduced

PCV- reduced 

RBC count -reduced



CUE-  

Albumin in urine



RANDOM BLOOD SUGAR-







X-RAY:






















ECG-




RFT:

 Serum urea and creatinine- raised.


LFT:








SERUM IRON:

USG ABDONEN:

Grade-II renal parenchymal disease
















PROVISIONAL  DIAGNOSIS:

CHRONIC KIDNEY DISEASE WITH HEART FAILURE.

TREATMENT: 

Salt and fluid restriction

Tab. Nicardia 10mg T.I.D

Tab. Lasix 40mg B.D

Tab. Arkamin 100mg

Tab. Unifer

Capsule. Gel cal D3

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Final examination general medicine

50 YEAR OLD FEMALE WITH WEAKNESS ON LEFT SIDE OF BODY


I have been given this case to solve in an attempt to understand the topic of "Patient Clinical Data Analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and diagnosis with a treatment plan. 


 This is an online E log book to discuss our patient’s de-identified health data shared after taking her guardian’s signed informed consent. 


A 50 year old right handed lady, who is a farmer by occupation, hailing from Vardhamanapeta came with 


Chief Complaints:  

  1. Weakness of left upper limb and lower limb since 5 days. 
  2. Slurring of speech since 5 days. 
  3. Deviation of angle of mouth to right since 5 days. 

History of Presenting illness: 

She was apparently asymptomatic 5 days back. 

On 20th of April,
She woke up and did her routine activities like brushing and cooking food. 
At 8:30 AM, she went to wash her face and experienced weakness of Left Upper limb and Lower limb, which was sudden in onset, leading to a fall associated with loss of consciousness from which she recovered spontaneously 5 minutes later. 
She complains of giddiness at the beginning of attack. 
She also experiences slurring of speech which was sudden in onset and gradually progressive. 
This is associated with drooling of saliva and deviation of angle of mouth towards right side while speaking, eating and showing teeth. 

She is unable to comb her raise and mix her food.
She is unable to squat and has difficulty in wearing slippers. 

She was brought to the hospital at 6pm. 

There is no history of involuntary movements. 

No history of loss of bowel and bladder control. 

No history of vomiting, convulsions, double vision, nasal regurgitation or nasal intonation. 

No history of head injury, fever, palpitations, chest pain or breathlessness. 

No history of similar attacks in the past. 

No history of memory impairment. 

No history of waxing or waning of symptoms. 

Past History: 

No history of similar complaints in past. 

She is a known case of Hypertension and diabetes mellitus since 8 years and is on medication for it. 

There is no history of tuberculosis, bronchial asthma, COPD, rheumatic fever or epilepsy. 

No history of recent weight loss. 

Drug history: 

She has been taking the following drugs since 8 years: 
  • Telmisartan 5mg 
  • Prazosin 5mg 
  • Teneligliptin 
  • Glimepiride, Voglibose and Metformin 
No history of any drug allergies. 












Family history: 
No history of similar attacks in other family members.

Personal history:

Diet: mixed 
Appetite: normal
Sleep: adequate 
Bowel and bladder movements: regular 
No addictions 

General examination: 

The patient is conscious, coherent and cooperative. 
She is moderately built and moderately nourished. 
She is lying in supine position in the bed. 

Temperature: afebrile 

Pulse: 78/minute, regular, normal in volume, no thickening of arterial wall felt, No radio radial or radio femoral delay seen. 

Blood Pressure: 130/90 mm Hg recorded on right arm in supine position. 

Respiratory rate: 18 cycles/minute

Pallor: absent 
Icterus: absent
Cyanosis: absent 
Clubbing: absent 
Koilonychia: absent
Lymphadenopathy: absent 
Edema: present and of pitting type 



Systemic examination

Central Nervous System examination

The patient is conscious, alert and cooperative. 

A) Higher mental function 
She is oriented to time, place and person.
Her speech is slurred. 
Her comprehension is intact and repetition is normal. 

B) Cranial Nerves
  1. Olfactory (I): can perceive smell
  2. Optic (II): Visual acuity- CF 2 in both eyes and field of vision- normal 
  3. Occulomotor(III), Trochlear(IV),Abducens(VI) : External ocular movements full in all directions. No nystagmus and no ptosis. Pupil reactive to light. 
  4. Trigeminal Nerve: Sensation over face present. Corneal reflex and Jaw jerk present. 
  5. Facial Nerve (VII): deviation of angle of mouth to right side. Loss of nasolabial fold on left side. Frowning present, upper half of face escaped. Drooling of food particles on left side. 



  2. Vestibulocochlear nerve(VIII): audition intact on both sides. 
  3. Glossopharyngeal(IX) and Vagus(X): gag reflex present. 
  4. Accessory(XI) and hypoglossal nerve(XII): normal 
C) Motor function

Nutrition: no wasting seen. 

Tone                              R.             L 
Upper limb.                Normal.      Decreased 
Lower limb.                Normal.      Decreased 


Muscle power 
Upper limb.              5/5.               1/5 
Lower limb              5/5.                3/5 

No involuntary movement. 




D)Sensory function

Superficial: pain, touch and temperature are intact. 

Deep: vibration sense, muscle sense, pressure sense, joint sense and position sense are intact. 

Cortical: one point localization, two point discrimination, stereognosis and graphaesthesia intact 

E) Reflexes 

Superficial 
                               Right.           Left 
Abdominal              Normal.       Lost
Plantar reflex          Flexor.        Extensor





Deep

Biceps jerk.           +2.               +2
Triceps jerk.          +2.                +1
Supinator jerk.      +1.                 -
Knee jerk.             +2.                +2 
Ankle jerk.              -                    -
Clonus                  Absent.        Absent 






Visceral
 Swallowing: normal 
Bladder: normal 
Bowel: normal 

F) Trophic Changes: absent 

G) Cerebellar function
Dysdiadochokinesia: absent. 
No nystagmus 





H)Autonomic function: normal 



Cardiovascular system

Peripheral arterial pulses: present 
Carotid pulsations present, no Bruit heard. 
S1 and S2 heard. No murmurs. 

Respiratory System

Shape of chest: Elliptical
Movement of chest: normal
Trachea: central in position 
Percussion: resonant on both sides
Breath sounds: vesicular 
Vocal resonance: normal on both sides 
Adventitious sounds: none 

Gastrointestinal Tract
Mouth, tongue, teeth, gum: NormalBowel sounds heard 




Investigations 
1. Chest X ray 
















2. CT Head



No hyperintensities or hypointensities seen.

3. ElectroCardioGram



Normal with heart rate 90 beats per minute. 



Treatment
1. Pharmacotherapy:
  • Rosuvastatin ( HMG CoA inhibitor) given to decrease the risk of stroke in the future. 
  • Pregabalin and Methylcobalamine: to treat nerve damage 






2. Physiotherapy 
                  

Provisional diagnosis: 

Based on the history, 
  • Anatomical localization: Infarct of Middle cerebral artery supplying the Right Internal Capsule. It is an upper motor neuron lesion. Upper motor neuron lesion of the VII nerve leading to facial nerve palsy on the same side of hemiplegia suggests that the lesion is above the pons. 
  • Pathological abnormality: Ischemia 
  • Biochemical abnormality: free radical release due to hypoxia 
  • Physiological abnormality: weakness of left upper limbs, lower limbs and left side of face. 

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Saturday, May 30, 2020

General medicine E- Log Paraparesis

                                           PARAPARESIS

May25, 2020
PRESENTED BY :    SHALVI     
ROLL NO.  - 149
8TH SEMESTER 
I've been given this case data to solve in an attempt to understand and analyize the topic "PARAPARESIS" based on patient clinical data in order to develop competency in reading and comprehending clinical data related to Paraparesis and come up with a suitable diagnosis.

You can refer to the case at 
UNDERSTANDING THE CASE
Patient suffers from bilateral symmetrical lower limb weakness and bilateral edema in both the legs

1] WEAKNESS IN BOTH LEGS

There is no weakness in the upper limbs and there is no cranial nerve involvement
Weakness in bilateral lower limbs started 2 yrs ago. It started as a proximal muscle weakness and over the years has now progressed to a distal weakness.Proximal muscle weakness since difficulty in squatting and getting up from that position. Distal muscle weakness suggested by difficulty in wearing and holding chappals.The weakness is insidious in onset and is gradually progressive in nature.


2) EDEMA IN BOTH LEGS

It is of non pitting type

Medical history:

Not a known case of hypertension, diabetes mellitus, epilepsy, thyroid. 

Family history : 

Not significant 

Personal history:

Diet  -mixed
Appetite - normal
Sleep- adequate 
Bowel and bladder movements - regular

Drug history :

The patient has no known drug allergies or use of any drugs. 

GENERAL EXAMINATION-

-patient was conscious, coherent and coperative
-moderately built and nourished.
-no signs of pallor, icterus, clubbing, cyanosis, lymphadenopathy, edema

-VITALS
1.temperature-AFEBRILE
2.pulse rate-92bpm
3.respiratory rate-18 cycles/min
4.BP-130/90mmhg
5.SpO2-96%
6.GRBS-142mg/dl

SYSTEMIC EXAMINATION


1. CVS-
S1 S2 heard
no added murmurs

2.RESPIRATORY SYSTEM-
-normal vesicular breath sounds heard
-bilateral air entry present

3.PER ABDOMEN-
shape=scaphoid
umbilicus=central and normal in position
all quadrants moving equally on respiration
no tenderness
no organomegaly
bowel sounds-heard
no bruit heard


2.RESPIRATORY SYSTEM-
-normal vesicular breath sounds heard
-bilateral air entry present

3.PER ABDOMEN-
shape=scaphoid
umbilicus=central and normal in position
all quadrants moving equally on respiration
no tenderness
no organomegaly
bowel sounds-heard
no bruit heard

4.CNS-
higher mental functions= normal
Cranial nerves- intact
Motor system-
       tone - normal
       power -  4-/5 in both lower limbs
        reflexes absent in both lower limbs
sensory system-normal
No meningeal signs
No cerebellar signs

DIFFERENTIAL DIAGNOSIS

1. Weakness -

 It can be Upper Motor Neuron or Lower Motor Neuron Disease

 Features of upper motor neuron lesion are:

  • Spasticity
  • Hypertonicity
  • Hperreflexia
  • Disuse atrophy (minimal)
  • Positive babinski's sign
Features of lower motor neuron lesion are:
  • Flaccidity
  • Hypotonicity
  • Hyporeflexia
  • Denervation atrophy(profound)
  • Negative babinski's sign
  • Fasciculations are present
In this patient there are no features suggestive of upper motor neuron lesion.

It  can be either upper motor neuron or lower motor neuron.  Since the patient has absence of reflexes, absence of any fasiculations, twitches and he has intact sensations therefore he can have a lower motor neuron lesion. 
                     

  LOWER MOTOR NEURON DISEASE

Lower motor neuron lesion : 
  • Anterior horn cell disease 
  • Nerve root ( radiculopathy) 
  • Plexus injury ( pain with sensory loss) 
  • Peripheral nerve disease
  • Neuromuscular junction
  • Muscle

ANTERIOR HORN CELL            

  • There is no sensory , autonomic or cerebellum involvement 
  • Affects distal muscles
  • There are fasciculations , wasting
  • It has asymmetrical onset

 RADICULOPATHY

  • Usually Asymmetrical 
  • Root pain is present along the distribution of nerve.
  • Sensory,motor systems involved and areflexia seen.
  • Muscles supplied by that particular nerve root are involved.
PERIPHERAL NERVE DISEASE

  • Motor and sensory involvement is seen
  • There is distal to proximal evaluation


They can be AXONAL or DEMYELINATING neuropathies.
AXONAL NEUROPATHY

It is a chronic polyneuropathy with distal to proximal evolution.Reflexes are usually spared unless it is a large fibre neuropathy.
There is predominant sensory involvement.


DEMYELINATING NEUROPATHY

It has a acute to subacute presentation and is a polyradiculoneuropathy.
There is diffuse proximal and distal muscle involvement.
Reflexes are lost.
There is predominant motor involvement.Sensory system if involved is mainly dorsal column involvement.


NEUROMUSCULAR JUNCTION

  • There is fatiguability
  • There is fluctuating weakness
  • There is ocular and pharyngeal muscle involvement 
MUSCLE
  • There is only motor involvement 
  • It has symmetrical onset
  • There is predominantly proximal muscle involvement 
  • There is no wasting
  • Reflexes are preserved
  • There are no fasciculations
FROM THE ABOVE DISCUSSION WE CAN CAN COME TO THE CONCLUSION THAT THE DIFFERENTIAL DIAGNOSIS CAN BE:

1) MYOPATHY
2)DEMYELINATING POLYNEUROPATHY

MYOPATHY


Myopathy refers to a clinical disorder of the skeletal muscles causing weakness of muscle. Abnormalities of muscle cell structure and metabolism lead to various patterns of weakness and dysfunction. In some cases, the pathology extends to involve cardiac muscle fibers, resulting in a hypertrophic or dilated cardiomyopathy. 
Disruption of the structural integrity and metabolic processes of muscle cells can result from genetic abnormalities, toxins, inflammation, infection, and hormonal and electrolyte imbalances.
IT CAN BE INTERMITTENT OR PERSISTENT WEAKNESS SINCE IT IS A CASE OF CONSTANT WEAKNESS IT CAN BE CLASSIFIED AS 
It can be further classifies into INHERITED or AQUIRED Myopathy 
Inherited muscle disorders are called muscular dystrophies:
  1. Duchenne's muscular dystrophy
  2. Becker's muscular dystrophy
  3. Limb girdle muscle dystrophy
  4. Emery Dreifuss muscle dystrophy
  5. Fascioscapulohumeral muscle dystrophy
  6. Myotonic dystrophy
  7. Mitochondrial myopathies
Dystrophinopathies(Duchenne and Becker's) are likely in this case.
  • Both have X-linked recessive inheritance due to a mutation in dystrophin gene.
  • Duchenne muscular dystrophy is a more severe form usually presenting before the age of 5. Proximal muscles of lower limbs are predominantly involved with positive gower's sign There is pseudohyperthrophy of calf muscles.They do not live longer because of serious cardiac conduction abnormalities and dilated cardiomyopathy.Therefore,Duchenne is unlikely in this patient.
  • Becker's usually survive into their 40's and have highly variable disease onset.
Acquired myopathies are due to the following causes:
  1. Inflammatory (Polymyositis/Dermatomyositis)
  2. Drug induced
  3. Endocrine

FURTHER INVESTIGATIONS REQUIRED:


  • Electromyography
  • Genetic testing
  • Creatinine phosphokinase levels;Increased in dystrophie
  • Nerve conduction study:Demyelinating neuropathies show slowing of conduction velocities, prolongation of distal latency
  • Muscle biopsy 
              

TREATMENT: 


Presently there is no cure for muscular dystrophy.
  • Corticosteroids- increase muscle strength and slow progression
  • Heart medications if associated with any heart conditions
  • Physiotherapy
  • ACE INHIBITORS/ ARB’s and Beta blockers to treat cardiomyopathy 

Following are my reference:


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