GENERAL MEDICINE ASSIGNMENT
GENERAL MEDICINE
1) Peer review
https://ankesh017.blogspot.com/2021/07/bimonthly-assignment-of-medicine-for.html
Overall the assignment is authentic, complete and very well formatted. Coming to the review of each individual answer:
A. Peer review has been done for a pulmonology case and its related questions. Both qualitative and quantitative rating has been given for each answer and the rating is justified by giving further comments on the positives and negatives of each answer.
Note has been made of answers citing sources and diagrams or flowcharts which makes the standard of review clearly understandable. A timeline of symptomology, pharmacological interventions and relevancy of each treatment have been given higher importance, thus answers including these are rated higher.
B. Case study is of a 52 year old man with infective endocarditis secondary to UTI. History is well charted and very elaborate. Standard format of case sheet has been followed. Diagnostic tests have been mentioned clearly and have been adequately deidentified. Video has been added for 2D echo. Treatment method is largely pharmacological.
Day wise treatment plan can be included for a better ELOG. Also some rehabilitation treatment plans can also be included in discharge summary.
C. Critical appraisal of patient data and analysis. Very elaborate answers have been written. Each case has been reviewed under its positives and negatives. Each aspect of the question ie. completeness, correctness, and ability to assess leads has been mentioned seperately.
3) and 4) Case reviews
AKI & CKD :
The given case is of a 75 year old man with chief complaints of lower back pain for 10 days along with oliguria, pedal edema, sob & involuntary movements of limbs since 10 days. Patient has a history of jaundice 3 years ago treated by plant based treatment. No known case of HTN, TB & DM. On general examination of CNS , slurred speech was seen with slightly reduced left upper and lower limb power with increased tone on lower leg. All reflexes were elicited. Severe anaemia is seen with increased blood urea and creatinine.
Provisional diagnosis - Acute kidney injury with chronic renal failure. Uremic encephalopathy and uremia induced tremors
Complaints & problems
Oliguria, burning micturition
Sob grade 4
Elevated serum creatinine & blood urea
Encephalopathy and tremors
Solutions
IVF given - to induce maturation
Salt restricted
Bp regularly monitored
Diuretics given
Foleys catheter
Load on kidney reduced & patient is released on diuretics. Kidney will heal over time
Patient with coma and renal failure :
This is a case of a 35 year old female with diabetes mellitus type 2 and SOB. Lower back pain since 5 days with abdominal and chest pain. At time of admission GRBS was 580mg/dl, back pain since one year and worsened upon administering non-prescription antibiotics. Patient was immediately intubated as they were gasping for air. SpO2 60% was recorded. Severe Metabolic acidosis seen. Patient was stabilised but still remains in a comatose state. gangrene Formed on thigh removed surgically.
Provisional diagnosis - DKA coma and AKI due to diabetic nephropathy
Complaints and problems
Fever and SOB
High blood sugar levels
Low blood pH
Patient is comatose
Gangrene
Solutions
Regular ABG done and pH maintained
SOB stabilised by intubation
High Sugar levels maintained by 10 units of insulin
Gangrene treated by cutting off flesh and underlying muscle
This is a case of a 52 year old with chief complaints of abdominal distension since 7 days. Patient asymptomatic till 2 years ago then non healing injury to foot. Diagnosed with DM type II and was started on GIMI M2. Patient was admitted 7 days ago and 5 days ago they experienced constipation and altered sleeping patterns.
Diagnosis -
INFECTIVE ENDOCARDITIS
WITH AV VEGETATIONS WITH MODERATE AS SEVERE AR
WITH AKI
WITH ?UREMIC ENCEPHALOPATHY ? SEPTIC ENCEPHALOPATHY
WITH ULCER OVER SOLE OF RIGHT LEG
WITH HYPOALBUMINEMIA ? ALCOHOLIC LIVER DISEASE
WITH ACUTE MULTIPLE INFARCTS IN BILATERAL CEREBRAL AND CEREBELLAR HEMISPHERES
Treatment given:
Day 1:
1. Inj. Monocef 1gm IV/BD
2. Inj. Vancomycin 500mg IV/BD in 100ml NS over 1hr
3. Proctoclysis enema
4. Inj. Pan 40 mg Iv/OD
5. Inj. Thiamine 200 mg in 100ml NS /BD
6. Inj. HAI 6U S/C TID
Day 2&3:
Same treatment followed
Day 4:
Same treatment followed except Inj. Monocef.
Inj. Augmentin 1.2 gm IV/TID
Tab. Ecosprin 150mg PO/HS/SOS
Tab. Clopidogrel 75mg PO/HS/SOS
Tab. Atorvas 20mg PO/HS/OD added
Advice at Discharge:
1. Inj. Vancomycin 500mg IV/BD in 100ml NS over 1hr
2. Inj. Pan 40 mg Iv/OD
3. Inj. Thiamine 200 mg in 100ml NS /BD
4. Inj. HAI 6U S/C TID
5. Inj. Augmentin 1.2 gm IV/TID
6. Tab. Ecosprin 150mg PO/HS/SOS
7. Tab. Clopidogrel 75mg PO/HS/SOS
8. Tab. Atorvas 20mg PO/HS/OD added
C) AKI :
The given case is of a 58 year old male with chief complaints of lower abdomen pain since 1 week with burning maturation & oliguria. Fever & sob (grade 4) is also seen. Patient has use of NSAIDs for back pain & headache and has common bouts of blurred vision & blackouts. 13 years ago trauma to head and is a known case of hon but not under medical management. Regular alcohol intake is seen up to 3 times a week. During physical examination high bp seen (140/90 mm Hg ) and GRBS of 113mg% was seen, tenderness around suprapelvic with pain on the right flank seen. Pus in urine with negligence albumin but elevated levels of serum creatinine [5.9] & blood urea (129) are seen.
Provisional diagnosis given - AKI due to idiopathic causes. Causes suspected include DM2 but no history seen, right ventricular heart failure but physical exam normal. Therefore HTN suspected but the ultimate cause was not determined.
Complaints & problems
Oliguria, burning micturition
Sob grade 4
Hypertension - 140/90 mm Hg
Elevated serum creatinine & blood urea
Solutions
IVF given - to induce maturation
Salt restricted
Bp regularly monitored
Diuretics given
Foleys catheter
Load on kidney reduced & patient is released on diuretics. Kidney will heal over time
D) CKD :
This is a case of a 49 year old female who had a mass 13 years ago with bleeding and was operated for hemorrhoids. Has been on NSAIDs for the past 3 years for muscle aches. Has had 20 days of fever and general weakness. Has been vomiting for 3 days. No SOB seen and urine output is normal. No significance seen in personal history. Physical examination shows restricted right and left knee joint movement and very deep pallor. Complete blood profile shows Dimorphic anaemia is seen along with very low RBC count. Bilirubin elevated but conjugated bilirubin normal therefore excess breakdown of RBC is seen. LFTs are normal. Hence RBC formation is suspected and Bone Marrow biopsy is aspirated
Provisional diagnosis - Multiple myeloma (plasmacytosis 70%)
Complaints and Problems
Fever and General weakness
Severe and dimorphic Anaemia
Jaundice
Solutions
Erythropoietin injections are prescribed twice a week for the anaemia.
Referred to higher centre
This is an interesting case because the symptoms do not coincide with the classical presentations of Multiple myeloma. This is also seen in the other case seen by Dr Rakesh Biswas in 2009 where a 47 year old with lower back pain presented to the OP. Even after multiple ways to find the source of acute renal failure the cause could not be found. Finally after a month a CT and a bone biopsy showed the presence of multiple myeloma. This case helps us learn about multiple methods of presentation of the same disease.
Link to case by Dr. Rakesh Biswas : https://casereports.bmj.com/content/2009/bcr.03.2009.1726#article-bottom
E) Patients with acute on CKD :
a) Case link: https://kavyasamudrala.blogspot.com/2021/05/medicine-case-discussion-this-is-online.html?m=1
This is a case of a 52 year old man with diabetes mellitus type 2, 3 months of burning micturition with no association of fever, He was diagnosed with Prostatomegaly (60gm) and advised TURP. Underwent TURP. Returned to hospital with complaints of excessive drowsiness and excess sleep. On the third admission there was high grade fever and burning micturation since 4 days. Creatinine levels 10mg/dl. Normalised and discharged. Finally admitted again with High grade fever and pus in urine. General examination revealed very low haemoglobin with anaemia and elevated serum creatinine. Blood urea was also slightly elevated with a drop in levels of sodium.
Probable diagnosis - Renal AKI with urosepsis and DM since 5 years and Diabetic nephropathy with anaemia due to CKD
Complaints and problems
Fever and Burning urine
Pus in urine
Prostatomegaly
Elevated blood sugars
Solutions
Antibiotics for Prostatomegaly and pus in urine
TURP procedure for Prostatomegaly
Diuretics for oliguria and burning urine
Huminsulin for elevated blood sugars
Case link: https://rishikakolotimedlog.blogspot.com/2021/07/45-year-old-male-with-chief-complains.html?m=1
This is a case of a 48 year old man with acute shortness of breath worsening from Grade 2 to 3 to 4 from the past 4 days. 2 years back he was diagnosed with Chronic renal failure and was given symptomatic treatment for the same. 7 months ago the patient had chest pain with heart failure and after an angiogram he felt wrong. SOB over the course of 2 months increased in grade over the course of last week. On general examination pedal oedema, dyspnoea present but wheezing absent. No abnormalities seen in CNS examination with 15/15 on the Glasgow scale. FBS and PLBS elevated, Complete blood picture showed low HB.
Provisional diagnosis - HFrEF reduced ejection fraction secondary to CAD and CRF
Complaints and problems
Shortness of breath
Solutions
Beta blockers given to help with the congestive heart failure and elevates the shortness of breath.
This is a case of a 60 year old female with SOB and Anasarca. She has had oliguria for the past 3 days. Vomiting and loose stools 5 days ago and subsided. History of SOB since 15 years and 10 to 15 episodes a year. 2 months ago pneumonitis with type 1 respiratory failure. On examination elevated blood Urea is seen along with Serum creatinine. SpO2 reduced to 80% in room air.
Provisional diagnosis - Left ventricular failure causing reduced ejection fraction secondary to CRF
Complaints and problems
Shortness of breath
Solutions
Beta blockers given to help with the congestive heart failure and elevates the Shortness of breath
F)Patients with AKI :
This is a case of a 43 year old male with complaints of loose stools for 20 days and pedal edema with abdominal distension. Chronic alcohol intake is seen and history of jaundice, 2 years ago. Pallor is seen but icterus is absent.
Provisional diagnosis-
ALCOHOLIC HEPATITIS ,
AKI SECONDARY TO ACUTE GASTROENTERITIS
HFrEF SECONDARY TO CAD
ALCOHOLIC AND TOBACCO DEPENDENCE SYNDROME
Complaints and problems
Pedal edema
Abdominal distension
Jaundice
Solutions
Diuretics given for pedal edema.
For jaundice the patient was asked to stop alcohol and thiamine injection was given.
This is a case of a 60 year old with chief complaints of pedal edema since 10 days with high grade fever and oliguria. The patient was diagnosed with DM2 5 years ago. In 2019 she was diagnosed with AKI and secondary urosepsis and resolved with dialysis. Burning micturition seen along with oliguria. Occasional alcohol consumption. Pallor is seen but no icterus. High BP is seen with 170/110 mm Hg.
Provisional diagnosis: Acute kidney injury secondary to urosepsis with hyperkalemia and anaemia
Complaints and problems
Acute kidney injury with urosepsis and burning micturition
Hyperkalemia
Anaemia
Hypertension
Solutions
Iv fluids and diuretics given for AKI and urosepsis
NSAIDs for pain
Anti hypertensives
Case link: http://chavvaclassworkdecjan.blogspot.com/2021/06/pancreatitis-in-chronic-alcoholic-with.html?m=1
This is a case of a 31 year old male with abdominal pain since 1 week, epigastric pain, non radiating and relieved upon sitting. Bilious vomiting since one week. Complains of SOB since 2 days. Patient hospitalised one week ago. Creatinine elevated to 7.6 after admission. Hard liquor since 4 years, regularly. Last intake of 360 ml one week ago. Chewing tobacco since 10 years. BP elevated. Sp o2 88% in normal air. GRBS normal. Slight tremors seen. Distension of abdomen seen with epigastric and hypogastric tenderness.
Provisional diagnosis - Acute pancreatitis with associated AKI. Patient in alcohol withdrawal.
Complains and problems
Bilious vomiting
SOB
Creatinine elevated to 7.6
Alcohol withdrawal
Elevated BP
Sp O2
Solutions
I/O charting for AKI
Hemodialysis for AKI
CECT abdomen was done
Case is still ongoing and the case log will be updated when further treatment is given.
5) Review on my online posting experience:
During the span of 2months I have experienced and seen many cases which are really helpful in clinical way. I have learned many things during the posting session.Even i have got a chance to log for a case the experience was quite helpful for me in understand how the system works. The General medicine department has done a quite a good work in making us understand the subject. For every clinical case they have guided us how to study and analize the case. I have learned how to capture the patient centred data for diagnosing the diseas. I have got a chance to see the many types of investigations done in order to diagnose a disease. I am grateful for this opportunity to involve in these study.
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