General medicine monthly assessment

 Harinarthini Vaishnavi 

This is online elog book to discuss our patient's de-identified health data shared after taking his /her /guardians signed informed consent. Here we disuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs.

LONG CASE 

44 year old male With Death of bilateral symmetrical Oedema and progressive generalised oedema 

The case was very well presented with adequate information for easy diagnosis  

Provisional Diagnosis - Acute Glomerulopathy (Glomerulonephritis / Nephrotic syndrome)

Features to look for - 

Hypertension (secondary hypertension in Glomerulonephritis)

Haematuria on Urine Microscopy (particularly dysmorphic RBCs in urine)

Quantification of Proteinuria

Serum Albumin / Total Proteins

Urine specific gravity / calculated urine osmolality to check for isosthenuria (to look for secondary tubular/interstitial damage) 

 Renal biopsy, if diagnosis remains uncertain

Pulse - 92 bpm, regular, normal volume, condition of vessel wall - normal, no radio-radial or radio-femoral delay. All peripheral pulses were normal.

Blood Pressure - 140/90 mmHg

Temperature - 99.3F

Respiratory Rate - 24 cycles per minute. Mildly acidotic + (with prolonged duration of expiration)

Diagnostic approach 

Secondary Hypertension

- Oliguria (360 ml urine in the last 24 hours)

- Hypoalbuminemia (Serum Albumin 2.5g/dl) and Anasarca

- Dysmorphic RBCs in Urine

Final 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.

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

SHORT CASE 

Q1) 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.

General Examination

Patient is conscious, coherent & cooperative.

Vitals at the time of history taking -

PR - 88 bpm

BP - 190/110 mm Hg

After standing for 3 mins - BP - 160/110 mm Hg

Temp - Afebrile

RR - 16 cpm

No signs of Pallor, Icterus, Cyanosis, Clubbing, Generalized lymphadenopathy or edema.

This case Was very well presented and easily understood for the diagnosis 

Cerebellum 

Head Impulse - negative

Nystagmus - negative

Test for skew - negative

Gait Ataxia absent.

Dysarthria absent.

Rebound phenomenon absent.

Intentional tremors - absent.

Respiratory System

Shape & symmetry of chest - Normal

Respiratory movements - Equal on both sides

BAE+

NVBS

Abdominal Examination

Soft, Non-tender

No organomegaly 

Bowel sounds+

Problem Representation -

A middle aged man presenting with a 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

Short case 

THE GIVEN CASE IS ADEQUATE TO DIAGNOSE THE CASE 

Q2) 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.

O/E : Pt was c/c/c 

BP - 160/100 mmHg 

Pr - 96 BPM ,regular ,normovolemic .

Rr - 18/min 

Spo2- 98% on ra.

Weight - 63 kg.

Height - 175 cm.

GENERAL EXAMINATION : 

NO pallor ,icterus ,cyanosis , clubbing, lymphadenopathy.

Pedal edema present - pitting type extending upto knee.

Abdominal distension present.

Moon face present

Pink striae noted over anterior abdominal wall and on low back and on upper arms and thighs.

Thin skin present . 

Poor healing noticed over leg ulcers and easy bruising noted .

Acne present over face .

Acanthosis nigrans noted over neck.

GYNECOMASTIA PRESENT .

Buffalo hump present .

Sparse scalp hair .

FINAL DIAGNOSIS : 

IATROGENIC CUSHINGS SYNDROME 

TREATMENT 

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