General Medicine Internship OSCEs and workflow done during internship rotation!
I AM P HRUDAII , 2018 batch INTERN.
I THANK DR. RAKESH BISWAS SIR HOD
This is a compailation of work blogs and PAJR created during my medicine rotation!
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 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-centred online learning portfolio and your valuable inputs on the comment box is welcome."I've 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 come up with a diagnosis and treatment plan.
PSYCIYATRY:
CASE 1 :
A 40 Y OLD FEMALE CAME TO THE OPD WITH C/O OF LOW MOOD GETTING TRIED EASILY SUCIDAL IDEASDISTRUBED SLEEP REDUCED CONCENTRATION AND ATTENSION SINCE 6 MONTH
THINKING ABOUT BROTHER AND SISTER WHO PASSED WAAY 10 YR AGO BUT SUDDENLY THINKING ABOUT THEM
H/O OF SUCIDAL ATTEMPTS IN SECOUND DEGREE RELATIVE
AND CONSULLTED PSYCHIATRIST 4 MONTHS AGO AND SHE IS ON
TAB ESCITALOPRAM 5MG
TAB CLONAZEPAM 0.25MG
TAB FLUPENTHIXOL 0.5 MG
TAB MELITRANCEN 10MG
TAB MODAFIMIL 100MG SINCE 2 MONTHS AND SHE IS USING IT IRREGULARLY AND NO IMPROVEMENT
H/O FEAR EPISODES WITH PALPITATIONS SOB CHEST TIGHTENESS TREMORS SWEATING OF HANDS SINCE 2 MONTH INCREASED SINCE 1 MONTH
MSE
THOUGHT - PREOCCUPIED ABOUT PHYSICAL HEALTH
PAST H/O : H/O OF EPISODES OF SAYING SOMEONE IS TALKING TO HER AND SOME ONE IS COMING INSIDE HER AND THIS SYMPTOMES WOULD OCCUR ONLY AT NIGHT RESOLVED WITH IN A WEEK
IMPRESSION : MODERATE DEPRESSION WITH ANXITY SYMPTOMES
RX
PATIENT IS EDUCATED
BREIF COUNSILLING IS DONE
TAB ESCITALOPRAM 5MG +TAB CLONAZEPAM 0.25MG
TAB CLONAZEPAM 0.25MG PO/SOS
TAB LITHIUM 400 MG
CASE 2 :
A 20yr old male came with complaints of visual and auditory hallucinations since 5yrs.
Loss of interest in doing activities,suicidal thoughts, trust issues,
,H/o alcohol and smoking consumption to overcome stress
IMPRESSION : Schizophrenia
Rx :
Tab.Olimelt 2.5mg
Tab.suprabenz plus 10 mg
Divaa 500 oral solution
Carbloom
FOLLOW UP
After taking medications his hallucinations were improved
And stopped consuming alcohol and smoking
ICU AND NEPHRO :
CASE 1 :
Chief Complaints -
60 year old female presented with complaints of ulcer over the left since 1 month.
History of Present Illness -
Patient
was apparently alright 1.5 month ago when she developed blisters over
left leg and foot which progressed to form a necrotic ulcer over the
left leg.
She has associated loss of appetite and generalized weakness since 1 month.
It is associated with pain and intermittent fever. It is also associate with discharge.
No history of trauma.
No history of similar complaints in the past.
https://www.blogger.com/u/2/blog/post/edit/9208620859043147249/6270597389493190231?hl=en
PAJaR LINK :
https://chat.whatsapp.com/CXQAH5C8gCb8K0Chom97YE
OSCE QUESTION :
WHAT ARE THE DRUGS CAUSING HYPOGLYCEMIA ?
WHAT ARE THE CAUSES OF HYPOGLYCEMIA IN ADULTS ?
First, pursue clinical clues to potential hypoglycemic etiologies—drugs, critical illnesses, hormone deficiencies, nonislet cell tumors. In the absence of these causes, the differential diagnosis narrows to accidental, surreptitious, or even malicious hypoglycemia or endogenous hyperinsulinism. In patients suspected of having endogenous hyperinsulinism, measure plasma glucose, insulin, C-peptide, proinsulin, β-hydroxybutyrate, and circulating oral hypoglycemic agents during an episode of hypoglycemia and measure insulin antibodies."
https://academic.oup.com/jcem/article/94/3/709/2596247
DOES SEPSIS CAUSE HYPOGLYCEMIA ?
Hypoglycemia has rarely been described as a clinical sign of severe bacterial sepsis. We recently encountered nine patients in whom hypoglycemia (mean serum glucose of 22 mg/dl) was associated with overwhelming sepsis. Clinical disease in these patients included pneumonia and cellulitis; in three patients, no focus of infection was apparent. Altered mental status, metabolic acidosis, leukopenia, abnormal clotting studies and bacteremia were common features in these cases. In four patients, no cause for hypoglycemia other than sepsis was present. In five patients, another possible metabolic cause for hypoglycemia was present (alcoholism in four and chronic renal insufficiency in one) although none had been observed to be hypoglycemic on previous hospitalizations. Streptococcus pneumoniae (three cases) and Hemophilus influenzae, type b, (two cases) were the most common pathogens, and the over-all mortality was 67 per cent. The mechanism(s) for hypoglycemia with sepsis is not well defined. Depleted glycogen stores, impaired gluconeogenesis and increased peripheral glucose utilization may all be contributing factors. Incubation of bacteria in fresh blood at room temperature does not increase the normal rate of breakdown of glucose suggesting that the hypoglycemia occurs in vivo. Hypoglycemia is an important sign of overwhelming sepsis that may be more common than has previously been recognized.
study : https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8785236/
CASE 2 :
PATIENT WAS APPARENTLY ASYMPTOMATIC YESTERDAY SHE GRADUALLY DEVELOPED ALTERED SENSORIUM SINCE MORNING AND NOT PASSING URINE SINCE MORNING.
NO H/O FEVER, COUGH, COLD, VOMITING. DIARRHOEA, SEIZURES.
PAST HISTORY: K/C/O DM, HTN ON MEDICATION.
NO H/O TB, ASTHMA, EPILEPSY.
SIGNS OF PALLOR PRESENT
SYSTEMIC EXAMINATION
CVS S1 , S2 + , NO MURMURS
RS BAE + , NVBS
P/A SOFT , NON TENDER ,NO ORGANOMEGALY
CNS:
1. HIGHER MENTAL FUNCTION
MEMORY-
IMMEDIATE: NO
IMPLICE: NO
LONG TERM MEMORY: NO
2. GCS:
EYE RESPONSE
EYE OPENING- SPONTANEOUS- 4
MOTOR RESPONSE: OBEY COMMANDS- 6
VERBAL RESPONSE: ORIENTED- 5
TOTAL SCORE- 15
3. NECK RIGIDITY:
BRUDZISKI SIGN- NO
KERNIG SIGN- NO
4. CRANIAL NERVES: ALL CRANIAL NERVES INTACT
RIGHT LEFT
BULK: UL N N
LL N N
TONE: UL N N
LL N N
POWER:UL 4/5 4/5
LL 4/5 4/5
REFLEXES: RIGHT LEFT
B + +
T - -
S - -
K NOT ABLE TO ELICIT
A NOT ABLE TO ELICIT
PLANTAR EXTENSION FLEXION
SENSORY:
FINE TOUCH: + +
CRUDE: + +
PRESSURE: + +
PAIN: INCREASED INCREASED
VIBRATION: + +
2 POINT DISCRIMINATION- NOT ABLE TO ELICIT
JOINT POSITION-NOT ABLE TO ELICIT
STEROGNOSIS-NOT ABLE TO ELICIT
COORDINATION:
1)FINGER NOSE-NOT ABLE TO ELICIT
2)KNEE HEAL-NOT ABLE TO ELICIT
3)DYSDIDOKOKINESIS:NOT ABLE TO ELICIT
JOINT-LOCAL RISE OF TEMPERATURE +
INCREASED PAIN SENSITIVITY BELOW THE HIP
INCREASING FROM HIP TO TOE IN SENSITIVITY
CASE BLOG LINK
OSCE QUATIONS :
WHAT IS of DRUG INDUSED leukocytoclastic vasculitis ?
STUDY LINK :
https://emedicine.medscape.com/article/333891-clinical?form=fpf
NEHRO :
1 Learned about dialysis process and dialysis machine
https://my.clevelandclinic.org/health/treatments/14618-dialysis
2 assisted in central line
ON UNIT MONTH :
CASE 3 :
C/o. Shotrness of breath 1 week
Cough 1week
Bl .pedal edema 1 week.
CASE BLOG LINK
https://chat.whatsapp.com/DHs0e7ogFxjBQspjX4aCVX
OSCE QUESTION :
1 How would you differentiate if this patient's pulmonary edema is cardiogenic or non cardiogenic?
Noncardiogenic pulmonary edema shows the classic “batwing” pattern of pulmonary opacities radiating centrifugally from the hila with air bronchogram. and cardiomegaly is also not seen
LINK :
CASE 4 :
Fever since 3 days and
Body pain since 3 days ,
Sob since 1 day GRADE II
c/o FEVER SINCE 3 DAYS
C/O BODY PAINS SINCE 3 DAYS
C/O SOB SINCE 1 DAY
PATIENT WAS APPARENTLY ASYMPTOMATIC 3 DAYS AGO THEN HE DEVELOPED FEVER
SINCE 3 DAYS HIGH GRADE FEVER CHILLS+ CONTINOUS TYPE INSIDIOUS ONSET
GRADUALLY PROGRESSIVE NO AGGREVATING AND RELIEVING FACTORS ASSOCIATE WITH
BODY PAINS AND GENERALISED WEAKNESS ASSOCIATED WITH SHORTNESS OF BREATH
SINCE 1 DAY GRADE II NO H/O COUGH NO H/O CHEST PAIN PALPITATIONS
OUTSIDE REPORTS PLATELETS 13000
CASE BLOG LINK
CASE 5:
A 44 YROLD MALE CAME TO OPD WITH
COMPLAINTS OF B/L PEDAL OEDEMA SINCE 6 MONTHS,
ABDOMINAL DISTENTION SINCE 6 MONTHS COUGH WITH OUT EXPECTORIATION SINCE 4 DAYS
PERSONAL HISTORY OCCUPATION AUTO DRIVER
ALCOHOL INTAKE DAILY SINCE 20 YRS 750 ML PER DAY
CIGERETE SMOKING SINCE 15 YR
CASE BLOG LINK :
C/O. SHORTNESS OF BREATH SINCE 1 MONTH
CHEST PAIN SINCE 1 MONTH
2d echo video : https://youtube.com/shorts/NsCPJIgtTJs?feature=share
BLOG LINK :
C/O
Deviation of mouth to right side
- Weakness of Left Upper Limb .and left lower limb
History of present illness:
He was apparently asymptomatic yesterday. Then as he was coming out of room he was unable to use left upper limb followed by which she developed deviation of mouth to the right side. It was associated with drooling of saliva from the right angle of mouth.. He was having sulring of speech .
- No c/o headache.
- No c/o nausea.
- No c/o fever.
- No c/o vomitings.
Past history:no similar complaints in the past
Deviation of mouth to right side.
Nasolabial fold on left side absent
No palor , icterus, cyanosis, clubbing, lymphadenopathy, Edema.
CNS:
GCS- E4V5M6
EOM- Full
Pupils- B/L dilated, reacting to light
Higher mental functions intact.
Sensory examination was normal
MOTOR SYSTEM:
Tone-. Rt. Lt.
UL N N
LL. N N
Power-
UL 5/5 1/5
LL 5/5 1/5
Reflexes- LINK https://youtu.be/AO7nDk1G_nM
R. L
B- ++ ++
T - ++ +
S- + absent
K- ++ +
A- + +
Provisional diagnosis-
CVA WITH LEFT HEMIPARESIS WITH ACUTE INFARCT IN THE .
RIGHT CORONA RADIATA EXTEDING TOWARDS RIGHT TEMPORAL LOBE
C/O FEVER SINCE 6 DAYS
PATIENT
WAS APPRENTLY ASSYMPTOMATIC 6 DAYS BACK THEN SHE DEVELOPED FEVR , HIGH
GRADE INTERMITTANT TYPE ASSOCIATED WITH CHILLS AND RIGORS RELIVED
TEMPOARARILY ON MEDICATION NO DIURNAL VARIATION
SINCE 2 DAYS ASSOCIATED WITH BODY PAINS
NOT ASSOCIATED WITH COLD COUGH VOMITINGA 40 yr old came to the causality with complaints of.
fever since 10 days
cough since 3 days
shortness of breath since 3 days
PAST HISTORY :
EVENTS
10 yr back he had an attack of fits and he went tto doctor he prescribed medication
|
5 yr back he again got an attack of episode of fits
|
3 days back he had a fever then he developed sob and cough . yeaterday he went to the suryapet hospital and there HE HAD PLAETLET COUNT IS 21 000 AND IGM POSITIVE DIAGNOSED AS DENGUE
then in night he came to the casuaity
fever since 10 days ,cough ,shortness of breath since 3 days fever is low grade assosiated with chills and rigours subsided with medication
cough is insidious and dry cough ,increased on lying down
sob since 3 days progressed form garde I to III
HE IS A CHRONIC ALCHOLIC SINCE 20 YR HE WILL DRINK 1 QUATER TO FULL IN EVER DAY
x ray
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