MBBS Record

Logbook

General Medicine

Name of the student:

Contact Number:

Date of admission to MBBS course:

Date of beginning of the current phase:

Reg. No. (College ID):

Reg. No. (University ID):

CERTIFICATE

Institute of Medical Sciences

This is to certify that ……………………………………………

Reg No……………...... has satisfactorily completed requirements Phase III Part II MBBS in GENERAL MEDICINE including related AETCOM modules as per the Competency-Based Undergraduate Medical Education Curriculum, Graduate Medical Regulation 2019 during the period from …….... ……….to ……………...

He/She is eligible to appear for the summative (University) assessment.

Faculty Mentor: Head of Department:

Name: Name:

Signature: Signature:

Place:

Date:

GENERAL INSTRUCTIONS:

(Quoted from Reference 1):

Singh, Tejinder & Aulakh, Roosy & Gupta, Priyanka & Chhatwal, Jugesh & Gupta, Piyush. (2021). Logbook for Pediatrics: Under-graduate competency-based curriculum of NMC. 10.13140/RG.2.2.18176.97287/1. Full text downloadable from : https://www.researchgate.net/publication/352350197_Logbook_for_Pediatrics_Under-graduate_competency-based_curriculum_of_NMC

1. This logbook is a record of academic and other activities of the student in the Department of Pediatrics. 2. Entries in the logbook reflect the activities undertaken by the student and certified by the faculty. 3. The student would be responsible for maintaining his/her logbook regularly. 4. The student is responsible for getting the logbook entries verified by concerned faculty regularly. 5. The logbook should be verified by the Head of Department before forwarding the application of the student for the University Examination. 6. The reflections should demonstrate the learning that has taken place. Don’t simply repeat the activities performed. Emphasize the learning experience, what you learnt and how it is going to be useful in future. At times, mistakes also provide great learning opportunities. Reflections provide a useful opportunity to document and assess learning for many competencies where there is no formal assessment. A deliberate effort should be made to teach the students to write academically useful reflections. Similarly, the teachers should acquire the skills for assessing reflections. 7. Using an electronic version of this logbook to facilitate documentation and retrieval of the work, is highly recommended and approximately 1000 such E log books starting from batch 2015 are available here :
http://medicinedepartment.blogspot.com/2022/02/?m=0

SECTION - A

Competencies in General Medicine

Competency-Based Medical Education (CBME) curriculum in General Medicine

More than 1000 competencies have been listed in General Medicine" under knowledge, skills, attitude and communication, rather meticulously and exhaustively in the NMC website here : https://www.nmc.org.in/information-desk/for-colleges/ug-curriculum/ (check out the freely downloadable PDF marked as UG curriculum vol II also downloadable from here : https://www.nmc.org.in/wp-content/uploads/2020/01/UG-Curriculum-Vol-II.pdf)

CLINICAL CASE PRESENTATIONS :

The department encpurages all their students to document all their clinical case presentations in separate E logged case reports (appropriately deidentified and after signed informed consent from the patient), with evidence of their verbal competencies in clinical problem solving and non verbal procedural videos reflecting their body language toward communication skills as well as certifiable procedural competencies.

All these are archived and displayed here

http://medicinedepartment.blogspot.com/2022/02/?m=0

for five batches starting from 2015 amounting to approximately 5000 case reports (and growing everyday)

REFLECTIONS: CLINICAL CASE PRESENTATION

(Students should preferably reflect on cases which they themselves have presented and focus on :

What happened?

So what?

What next?

Faculty signature Date

II. COMPETENCIES

A. COMPETENCIES REQUIRING CERTIFICATION*

1) Perform NG tube insertion in a manikin

Minimum number required to certify-2

Level of competency: Perform

Core: Yes

The student must perform this activity twice to be certified

Total Number Required : 1

Date	Attempt			Faculty decision		Faculty signature with date	Rating
Date	First F	Repeat R	Remedial Re	Completed	Not Completed	Faculty signature with date	Below expectation B	Meets expectation M	Exceeds expectation E

2) Perform IV cannulation in a model

Minimum number required to certify-2

Level of competency: Perform

Core: Yes

The student must perform this activity twice to be certified

Total Number Required : 1

Date	Attempt			Faculty decision		Faculty signature with date	Rating
Date	First F	Repeat R	Remedial Re	Completed	Not Completed	Faculty signature with date	Below expectation B	Meets expectation M	Exceeds expectation E

3) Assess airway and breathing: administer oxygen using correct technique

and appropriate flow rate

Minimum number required to certify- 3

Level of competency: Perform

Core: Yes

The student must perform this activity twice to be certified

Total Number Required : 1

Date	Attempt			Faculty decision		Faculty signature with date	Rating
Date	First F	Repeat R	Remedial Re	Completed	Not Completed	Faculty signature with date	Below expectation B	Meets expectation M	Exceeds expectation E

4) Check for signs of shock i.e., Pulse, Blood Pressure, CRT Minimum number required to certify- 3

Level of competency: Perform

Core: Yes

The student must perform this activity twice to be certified

Total Number Required : 1

Date	Attempt			Faculty decision		Faculty signature with date	Rating
Date	First F	Repeat R	Remedial Re	Completed	Not Completed	Faculty signature with date	Below expectation B	Meets expectation M	Exceeds expectation E

5)Provide BLS for adults in manikin Minimum number required to certify- 3

Level of competency: Perform

Core: Yes

The student must perform this activity twice to be certified

Total Number Required : 1

Date	Attempt			Faculty decision		Faculty signature with date	Rating
Date	First F	Repeat R	Remedial Re	Completed	Not Completed	Faculty signature with date	Below expectation B	Meets expectation M	Exceeds expectation E

SECTION - B

Evaluation and feedback on self-directed learning (SDL) - 10 hours

Sl no.	Date	Topic of SDL	Feedback	Signature of faculty/mentor
1
2
3
4
5
6
7
8
9
10

SECTION - C

AETCOM Modules Report

AETCOM Module Number:

Date:

Topic:

Competencies:

Reflections (100 words):

1. What did you learn from this AETCOM session based on the objectives?

2. What change did this session make in your learning?

3. How will you apply this knowledge in future?

Remarks by Facilitator

Signature of facilitator with date

AETCOM Module Number:

Date:

Topic:

Competencies:

Reflections (100 words):

1. What did you learn from this AETCOM session based on the objectives?

2. What change did this session make in your learning?

3. How will you apply this knowledge in future?

Remarks by Facilitator

Signature of facilitator with date

AETCOM Module Number:

Date:

Topic:

Competencies:

Reflections (100 words):

1. What did you learn from this AETCOM session based on the objectives?

2. What change did this session make in your learning?

3. How will you apply this knowledge in future?

Remarks by Facilitator

Signature of facilitator with date

Medicine Log book (paper printed version) with sample cases and proper ethical logbook sharing protocol

1st page

Dedication:

To our patients and students locally as well as globally

2nd page :

Foreword:

Log Book is a tool toward daily student reflective logging of their learning experiences and sharing them with peer learners for further feedback driven learning.

It was recognized by William Osler in his writings and to quote,

"Carry a small note-book, and never ask a new patient a question without note-book and pencil in hand . . . Begin early to make a three-fold category – clear cases, doubtful cases and mistakes and learn to play the game fair, no self-deception, no shrinking from the truth; mercy and consideration for the other man, but none for yourself, upon whom you have to keep an incessant watch. It is only by getting your cases grouped in this way that you can make any real progress in your postcollegiate education; only in this way you gain wisdom with experience. (Ref below)

More than 100 years later, the log book has been considerably tech enhanced in it's ability to derive global inputs in a weblogged format and the weblog has become so popular that it is now fondly known as "blog" for short.

This book published by the institution and our department is a guide toward making a good log book write up using selected guidance logs from our past illustrious students to enable newbies in their medicine learning journey. We hope this will be useful.

References:

Osler, W. (1904) Aequanimitas with Other Addresses to Medical Students, Nurses and Practitioners of Medicine. Philadelphia, PA: The

Blakiston Company.

Osler, W. (1928) The Student Life and Other Essays. London: Constable

2b)

Student statement :

"This is a paper based log book (with a corresponding E log version online) to discuss our patients de-identified health data, shared after taking his/her/guardian’s signed informed consent (check out the multilingual informed consent form template in the subsequent pages ahead). Here we discuss our individual patient’s problems through series of inputs from available local and global online community of learners and teachers with an aim to solve these patient’s clinical problems with collective current best evidence based inputs. This log book also reflects my patient-centered learning portfolio, also available as an online learning portfolio and your valuable peer review inputs will enable me to learn further as to help our patients better.

3rd page :

Global patient privacy and confidentiality policies

Global policies are based on global data protection laws and common laws of confidentiality. Most of the write up here is quoted and borrowed from BMJ's stance published here: https://www.bmj.com/about-bmj/resources-authors/forms-policies-and-checklists/patient-confidentiality

• Any report/article that contains personal medical information about an identifiable living individual requires the patient's explicit consent before it can be shared open access publicly. We will need the patient to sign a consent form, which requires the patient to have read the article. The consent form is available in multiple languages and the author must ensure that the form is in a language that the patient understands.

• If consent cannot be obtained because the patient cannot be traced, then publication/logging toward sharing will be possible only if the information can be sufficiently anonymised. Anonymisation means that neither the patient nor anyone else could identify the patient. A consequence of any anonymisation is likely to be the loss of information/evidence. If this happens we will include the following note at the end of the paper: "Detail has been removed from this case description/these case descriptions to ensure anonymity. The authors/loggers are satisfied that the information shared here backs up the case the authors are making." Such anonymisation might, at an extreme, involve making the authors of the article anonymous.

• If the patient is dead, global data protection laws may not apply, but the authors should seek permission from a relative (as a matter of courtesy and medical ethics). If the relatives are not contactable the author/logger needs to balance the worthwhileness of the case, the likelihood of identification, and the likelihood of causing offence if identified, in making a decision on whether we should publish without a relative’s consent.

• Children- Parents or guardians can consent on their behalf but children aged between 7 and 18 must also sign the consent form in addition to the parent or guardian. For younger children, even if parents consent, authors should consider whether the child, when older, might regret publication of his or her identifiable details.

• Patients who lack capacity - If the patient lacks the mental capacity to make a decision about publication then usually no one can give consent on behalf of the patient. Even if someone has this power, by means, for example of a health and welfare power of attorney, it has to be exercised in the best interests of the patient

Page 4:

Log Book authors need to download the template for the signed informed consent form available in multiple languages here:

http://medicinedepartment.blogspot.com/2020/05/informed-patient-consent-and.html?m=1

                                             Informed Patient Consent and Authorization
                 Informed Patient Consent and Authorization form for sharing of deidentified case report

I give my consent and authorization for this information about MY SELF/MY WARD/MY RELATIVE (indicate correct description) relating to my/his/her health to appear in an online E-log case record (case report) that will exist in social media such as whatsapp and facebook. I understanding the following:

1) Health professionals need to communicate about my problem with each other and share my detailed history as well as images of my body in clinical photographs, images of Radiology and other test reports. In the past this was routinely done using paper based files and in the electronic age as it is faster to communicate using electronic devices connected online, this is how my history and images will be shared, as an E log case report (other than the paper based file system that may still continue).

2) My information will be published online by my health-professionals without revealing my identity or any personal information such as identifiable names and numbers like phone numbers, PAN number, UID numbers etc., and Email addresses or house addresses and the professionals in the online forums will make every attempt to ensure my anonymity addressing me solely by my anonymized user-name.

3) I understand, however, that complete anonymity cannot be guaranteed. It is possible that after reading the E log case report, somebody somewhere- perhaps, for example, somebody who looked after me if I was in hospital or a relative-may identify me. The information that will be visible online will be the existing information that I provide in the form of patient input and new information will be added by many professionals processing my patient inputs in the online forum

4) The information may be published in online forums such as in whatsapp and facebook as well as in associated journals on paper as well as a blog in the internet as an E log case report and will be distributed worldwide

5)Information displayed in the E-log forum is not supposed to replace advice from the primary physician of the patient and my primary physician in charge will continue to look after me and make his own responsible decisions about my treatment.

6) The above information was explained to me in the language I understand.

Name & Signature of Consent   Giver

Signature of Guardian/ Relative,

Name & Designation of Consent Taker

(Anonymized Identifier)

Address :

Mobile No:

                                         *సమాచార సమ్మతి మరియు అధికార పత్రం*
విస్తరించిన విషయములు నాకు అర్ధమినివి:
నేను నా గురించి/ నా వార్డ్/ నా   బంధువు యొక్క ఆరోగ్య పరిస్థితుల గురించి ఆన్లైన్ ఈ లాగ్ కేస్ రిపోర్ట్ తయారు చేసి సోషల్ మీడియా లో అనగా (in social media platforms such as) ఫేస్బుక్(Facebook), వాట్సఅప్(whatsapp) లో పోస్ట్ చేయుటకు అనుమతి ఇస్తున్నాను. ఈ క్రింది విస్తరించిన విషయములు నాకు అర్ధమినివి:
1. నా ఆరోగ్య పరిస్థితులను, నా వ్యాధులకు సంబంధించిన టెస్ట్ రిపోర్ట్స్, రేడియాలజీ రిపోర్ట్స్ ఈతర డాక్టర్స్ తో చర్చించుటకొరకు ఆన్లైన్ ఈ లాగ్ కేస్ రిపోర్ట్ తయారు చేయపడుతున్నది. ఇంతకు ముందు ఈ విధమైన సమాచారాము కాగితపు రూపంలో జరుగుతుండేది. ఈ ఆన్లైన్ ఈ లాగ్ కేస్ రిపోర్ట్ ఎలెక్ట్రానిక్ పరికరాలతో సునాయాసంగా సులభంగా త్వరగా పంపవచ్చు.
2. నా పేరు, ఫోన్ నంబర్, పాన్, ఉఇడ్ నంబర్స్, ఈమేల్ అడ్రెస్ లను వెలువరించకుండా, నేను సమాచారం డాక్టర్స్ ఈ లాగ్ కేస్ రిపోర్ట్ లో ప్రచురిస్తారు. ఈ ప్రచురించిన ఈ లాగ్ కేస్ రిపోర్ట్కు తెలియని పెరు పెడతారు.

3. నా పూర్తి వివరాలు ఎవరు చూడకుండా, చదవకుండా దాచటం సాధ్యం కాకపోవచు. ఉదాహరణకు, నాకు సంబంధించిన విషయాలను నేను ఆసుపత్రి లో ఉన్నపుడు నా స్నేహితులు కానీ , బంధుమిత్రులు కానీ చూసి చదివే అవకాశం ఉంది. ఈ లాగ్ కేస్ రిపోర్ట్ లో ఉండే సమాచారం ద్వారా ఈతర డాక్టర్లు నా ఆరోగ్యముకు సంబంధించి ఆన్లైన్ లో చర్చించవచ్చు.

4. ఈ లాగ్ కేస్ రిపోర్ట్ ద్వారా సేకరించిన సమాచారం ఆన్లైన్ ఫోరమ్ లో, జర్నల్ క్లబ్ లో, జర్నల్స, సోషల్ మీడియా లో అనగా (in social media platforms such as) ఫేస్బుక్(Facebook), వాట్సఅప్(whatsapp) లో నా పేరు, వివరములు వెలువరించకుండా ప్రచురించవచ్చు.

5. ఈ లాగ్ ఫోరమ్ లోని ఎటువంటి సలహా సమాచారము వచ్చిన, నా ప్రస్తుత ప్రాథమిక వైధ్యుడు యొక్క సలహాలతో మాత్రమే మార్చబడును.నా చికిస్తకు సమబంధించిన పూర్తి    బాద్యత నా ప్రాథమిక వైధ్యుడిది.

6. ఈ పయ ప్రక్రియ అంతయు నాకు అర్ధం ఇయే భాషలోనూ వివరించబడినది.
సమ్మతి యొక్క పేరు మరియు సంతకం:
సంరక్షకుడు/ బంధువుల సంతకం:
దాత పేరు మరియు హోదా:

సమ్మతించు వాడి పేరు మరియు హోదా:
సమ్మతి ఐడి:
అడ్రెస్ :
సెల్ నంబర్ :

Page 5:

Sample logbooks of other students with

Long and short cases involving different anatomical locations and systems

CNS

LONG CASE:

Informant: Patient

A 38 year old male, a resident of chandanapally, nalgonda district came to the hospital with complaints of difficulty in walking since 8 years

Chief complaints: difficulty in walking since 8 years (2014 March)

Feeling weak during walking since 7 years (2015 January)

History of present Illness: The patient had difficulty while walking, while getting up from chair without support, but gets up from chair with support, difficulty in squatting, difficulty in sitting on floor, difficulty in getting up without support from floor.

Initially he had difficulty in going uphill but since 3 years he was complaining of difficulty in walking on level ground also.

Uphill: steps are difficult

Downhill: comparatively easier steps than uphill

Difficulty in running

The patient did not have any difficulty in wearing chappals, holding chappals. He did not have any problem in removing chappals. However he complained that it was easier to walk without chappals since there was lesser weight lifting needed.

After having these symptoms for 8-9 months the patient went to the hospital for checkup and was given medication for which there is no record of with the patient. According to the patient, he was not on regular medication and the medication didn’t improve his symptoms.

Overtime, he had feeling of heaviness of upperlimb while lifting his hand over the head which progressed over time to having difficulty in lifting his arm to shake hands , eat his food and take his brush from the cupboard. He complains that he has to give an increased initial try for him to lift his hand.

After initiating combing, he doesn’t have any difficulty in combing the hair. He feels that it is difficult to move the brush in his mouth.

Difficulty in lifting food to mouth. Not associated with falling of food particles and not associated with falling of food from mouth. No difficulty in chewing food after putting food in the mouth.

Difficulty in bathing with mug. Washes more on the right side with difficulty in washing on the left side.

Difficulty in getting from bed without support since 1 year. No difficulty in turning to sides on bed.

No difficulty in eating, chewing, closing eyes, swallowing food, whistling, shouting, winking.

Complaints of intermittent spasm of muscles after prolonged sitting. Complaints of muscle cramps.

No complaint of difficulty in feeling things he touches. No difficulty in feeling chappals sensation. As he walks without chappals he is used to pain while walking and says that his feet are more prone to injuries.

He doesn’t have any difficulty in feeling pain when there is an injury. He doesn’t have ulcerations or abnormal sensations anywhere on the body.

He is able to feel the temperature of the water while bathing.

Birth history: The patient had history of second degree consanguinity and was born at home with the help of dai and apparently without any problem after birth in his words.

He walked without support at 3 years and started talking in sentences at 7 years of age. He has stuttering while talking but doesn’t have a problem in formation of sentence, language or difficulty in pronunciation of words. He says that he stutters more when there is lack of sleep.

Family history: No history of similar complaints in the family. His mother and father died in an accident and he is not married due to his stuttering problem at first and weakness later.

Personal history: The patient was a smoker previous for 6 months in 2012 but stopped later. Occasional alcoholic.

Past history: The patient had a history of fall from cycle in 2012 after which he had a fracture in the left wrist but did not go to the hospital and took Ayurveda treatment. Now there is a deformity in the left wrist and reduced range of movement with difficulty in using the hand.

No known history of diabetes, hypertension, bronchial asthma, allergies, tuberculosis, jaundice or prolonged hospital stay.

Summary: Based on the above history the patient had slowly progressive weakness of the lower limbs more proximal than the distal and overtime it progressed to the upper limbs with more proximal weakness than distal and he developed weakness in the trunk overtime. He doesn’t have spasticity or rigidity in the muscles. He doesn’t have sensory complaints. He complains weakness more in the lower limbs than upper limbs. He has no cerebellar, autonomic system, cranial nerves or higher mental function abnormalities. The patient had history of consanguinity, delayed milestones and history of malunited left wrist fracture.

General physical examination: The patient is conscious, coherent, comfortable, cooperative. No distress or features of pain. The patient doesn’t appear pale.

There is no icterus, clubbing, cyanosis, pedal edema, generalised lymphadenopathy on examination.

Weight- 54 kgs

Height- 162 cms

BMI- 20.57 kg/m2

BP- 110/70mm Hg

Hair, nails, skin and spine- normal

Systemic examination:

Neurological examination:

Higher mental functions: The patient is conscious, appears comfortable, language and behaviour appears normal.

Orientation to time place and person normal. Mood and emotional status appears normal.

Memory: immediate, recent and remote memory tested- normal.

Mini mental status examination score- orientation-5/5

Registration-3/3

Attention and calculation- 2/5

Recall- 3/3

Total score- 25/30

No illusions or hallucinations

Speech: normal verbal output, fluency, repetition, naming, reading, writing.

Appearance- no tics, tremors, myoclonus, involuntary or voluntary movements

Motor examination:

Bulk:

upper limb- right upper limb- 24.5 cms above elbow, 22cms below elbow

Left upper limb- 23.5cms above elbow, 22 cms below elbow

Lower limb- right lower limb- 43 cms above knee, 32 cms below knee

Left lower limb- 43 cms above knee, 32 cms below knee

Tone: hypotonic in right upper limb and lower limb, hypotonic in left upper limb and lower limb.

Power: Right Left

Upper limb- distal flexors- -4/5 -4/5

Proximal flexors 3/5 3/5

Hand muscles- extensor pollicis longus- 3/5 on both sides, all the others are 4/5 power

Trunk muscles- 3/5 on both sides

Lowerlimb- hip muscles- iliopsoas- 3/5 on both sides

Adductor femoris- 3/5 on both sides

Hamstring muscles- 3/5 on both sides

Gastrocnemius muscles- -4/5 on both sides

Extensor hallucis longus- -4/5 on both sides

Coordination- normal coordination of movements

Reflexes: biceps- reduced but present + on both sides

Supinator- + on both sides

Triceps- + on both sides

Ankle - + on both sides

Plantar- flexor response on both sides

Sensory examination:

touch- normal on both sides

Temperature- both hot and cold sensation normal on both sides

Vibration- normal on both sides

Joint position- 5/6 times on right side, 6/6 times on left side

Cerebellar examination:

Hypotonia- present

No rebound phenomenon

Finger nose test- normal

Finger finger test- normal

Heel shin test- normal

No past pointing, intentional tremor or gait abnormalities.

Gait: normal stride, Normal width, normal turning, The patient is not able to walk on toes.

Cranial nerves:normal.

Autonomic system: no bowel bladder abnormalities, no abnormal sweating, no orthostatic hypotension, no postprandial syncopal attacks, no history of falls with loss of consciousness.

Intracranial pressure: no signs of raised intracranial pressure

Skull and spine: normal

Cardiovascular system:

Inspection: normal on inspection, no visible pulsation, apex beat not visualised. No visible lesions on chest. Equal and symmetrical chest movements with respiration.

Palpation: apex beat felt on the left 5th intercostal space 1cm medial to mid clavicular line. All the findings of inspection are confirmed.

Percussion- all the borders of heart normal on percussion

Auscultation- s1, s2 heard.

No added sounds, no murmurs heard, normal split heard in s2.

Respiratory system:

Inspection- normal on inspection, no visible pulsation, apex beat not visualised. No visible lesions on chest. Equal and symmetrical chest movements with respiration.

Palpitation- apex beat felt on the left 5th intercostal space 1cm medial to mid clavicular line. All the findings of inspection are confirmed.

Percussion- no abnormal findings on percussion

Auscultation- normal vesicular breath sounds heard equally on both sides

Abdominal examination:

Inspection- normal on inspection, no visible pulsations, no visible lesions on abdomen.

Palpation- no organomegaly

Percussion-

Auscultation- bowel sounds heard at normal frequency

Ecg-

Chest X-ray- normal

Serum creatine phoshokinase- 780 IU/ lit

Nerve conduction study- normal

Elctromyography- reduced amplitude with polyphasic motor response- suggests myopathy

Muscle biopsy report- Left quadriceps muscular dystrophy

Final diagnosis:

Based on the above history, examination and findings, the most probable diagnosis is progressing symmetrical proximal muscular dystrophy involving both lower limbs and upper limbs without any known family history or heart involvement so most probably could be beckers or limb girdle muscular dystrophy based on the above mentioned findings.

Differential diagnosis- the other possible diagnosis could be chronic inflammatory demyelination syndrome but it is predominantly sensory and in this case sensory findings are minimal.

Other possible diagnosis could be proximal motor neuropathy or neuronopathy but there is no history of diabetes or involvement of muscles of neck, swallowing.

Blog Link: https://2018-21batchpgy3gmpracticals.blogspot.com/2021/08/18100006009-case-presentations.html

SHORT CASE:

History given by patient and her husband and is reliable

A 45year old female, right handed ,housewife, resident of Nalgonda presented with

Chief complaints of

-headache since 2years

-Bilateral Knee,ankle,elbow joint pains since 6months

-weakness of right upper and lower limbs since 30days

-deviation of mouth to left since 30days

-Double vision since 10days

History of present illness:

Patient was apparently alright 2years back ,then she developed headache-acute in onset, Intermittent ,throbbing type,diffuse and bilateral .Not associated with nausea ,vomitings,photophobia,phonophobia, laceration,blurring of vision.

Complaints of bilateral Knee,ankle,elbow joint pains since 6months -not associated with fever,restriction of movements,early morning stiffness,swelling of joints -relieved by taking analgesics and aggrevated on exertion.

Complaints of weakness of right upper and lower limb since 1month -acute in onset and gradually progressive - initially she had mild symptoms ,that gradually progressed over 1 month to current status .Initially she used to walk alone till the bathroom With some difficulty ,later patient found difficulty in walking without support and patient felt more giddiness while walking.

Complaints of mild deviation of mouth to left side , not associated with drooling of saliva

Complaints of Double vision since 1month- intermittent ,horizontal and binocular ,no history of black spots,colored halos,floaters,blurring of vision.

Able to perceive taste sensation.

Past history:

Non Diabetic,Non Hypertensive, No history of Asthma,CAD,Epilepsy.
She underwent hysterectomy 20 years back.

Family history :

She was married at the age of 18 years ,3rd degree consanguinity

1 st child- spontaneous vaginal delivery - 25 yrs old

2 nd child-vaginal delivery, died at 1 month of age due to unknown reason

3rd child - died at the age of 21 due to kidney failure

No history of similar complaints in family.

Menstrual history:

Age of menarche : 15 years ,regular cycles-5/30 ,no dysmenorrhoea

Drug history:

Patient was on

T.ECOSPIRIN 75mg/PO/OD

T.ATORVAS 20mg/PO/HS

Summary:A 45 year old right handed female patient, who is non hypertensive and non Diabetic with no addictions presented with headache since 2years and progressive weakness of right upper and lower limb since 1month and double vision double since 10days.

Differential Diagnosis:

1. Cerebro vascular accident involving mid brain and Pons

2. Basilar artery occlusion

3. Demyelinating disorders

General examination:

Pt conscious,coherent ,cooperative oriented to time ,place and person

Moderately built and nourished .

BMI: 24.6kg/m²

Vitals

Pulse :

82beats per minute , regular, normal volume ,vessel wall normal ,no radio-radial delay ,no radio femoral delay, all peripheral pulses felt.

Blood pressure:

right arm -120/80mmHg ,supine position

Left arm -120/80mmHg ,supine position

Right leg - 130/80mmHg

Left leg -130/80mmHg

Respiratory rate- 16cycles per minute, thoracoabdominal ,no usage of accessory muscles.

Temperature - 98.2F

SpO2-98% at room air

JVP - not elevated

Physical examination:

No Pallor, icterus, cyanosis, clubbing, generalized lymphadenopathy, edema.

Systemic examination:

Patient is conscious,coherent and cooperative

Right handed person

MMSE - 30/30

Nystagmus -absent

Speech - spontaneous with intact naming ,repetition,fluency.

Spine –normal

Cranium –normal

gait -hemiplegic gait

Cranial nerves - right. Left

1.Sense of smell - normal. Normal

2.Visual acuity - normal. Normal

Field of vision- normal. Normal

colour vision. Normal. Normal

fundus. Normal. Normal

3,4,6 : extra ocular movements:

-restriction in adduction elevation,depression on right side and normal on left side

-pupils: Normal size and reacting to light on both sides

-direct and consensual light refleces normal in both eyes

No Nystagmus

no ptosis

5. Sensory : sensations over face normal on both sides

Motor - massager,temporarily, pterygoids normal

7. Motor : loss of nasolabial fold on right . Orbicularis ocular, orbicularis Oris ,occipital frontalis, buccinator -normal on both sides

Sensory : taste over anterior 2/3rd of tongue normal on both sides

8. Rinnes test normal on both sides

. Webers test normal on both sides

9.10. Uvula , palatal arch movements normal.

Gag reflex. - normal

Palatial reflex - normal

11. Tarpezium and sternocleidomastoid -normal

12. No wasting and fasciculations of tongue

Tongue protrusion to midline.

Motor system examination :

1.Bulk (nutrition): right. Left

Inspection. Normal. Normal

Measurements :U/L 26/22cm 26/22cm

L/L. 46/ 34cm. 46/34cm

2.Tone : U/L hypotonia. Normal

L/L. Hyportonia. Normal

3.power:

Neck muscles. 5/5. 5/5

upperlimb:

Shoulder- -4/5. 5/5

Elbow - -4/5. 5/5

Wrist - -4/5. 5/5

Handgrip- 50% 100%

Lower limb:

Hip - 3/5. 5/5

Knee- 3/5. 5/5

Ankle - 3/5. 5/5

Trunk muscles- normal.

Deep tendon Reflexes - right left

Biceps +++ +++

Triceps +++ +++

Supinator ++ ++

Knee. +++ +++

Ankle. +++ +++

Jaw jerk. Present

Superficial reflexes -

Corneal. + +

Conjunctival. + +

Pharyngeal. + +

Palatal. + +

Abdominal. + +

Cremastric. + +

Plantar. Extensor extensor

Sensory system examination:

Spinothalamic: right. Left

Crude touch - normal. Normal

Pain- normal. Normal

Temperature- normal. Normal

Posterior column

Vibration sense- normal Normal

Fine touch - normal. Normal

Position sense - normal. Normal

Cortical senses

2point descrimination- normal. Normal

Tactile localization - normal normal

Stereognosis - normal. Normal

Graphesthesia - normal. Normal

Cerebellar examination: right left

Finger nose test - normal. Normal

Finger nose finger test- normal. normal

Disdiadokinesia - no no

Heel knee test - normal. normal

Tandom walking. - could not be performed

Rombergs sign - could not be performed

Gait examination- hemiplegic gait

Spine examination- normal

Peripheral nerves - no nerve thickening,no foot or wrist drop .

Here are some videos of her CNS examination

Other systems

CVS : S1S2 + , No murmers , Apex normal

Respiratory system: Normal vesicular breath sounds +, no added breath sounds.

GIT : No abnormalities +

Provisional Diagnosis:

Sudden onset right sided hemiparesis which is gradually progressive , with right UMN type of Facial palsy and 3rd nerve involvement due to demyelinating/inflammatory etiology involving midbrain and Pons .

With the given history and examination we evaluated her further

MRI BRAIN (Plain and contrast )with Angiogram was done that showed

T2 hyperintensities noted along short T2 FLAIR showing hyperintensity right segment of Cervical cord internal capsule

T2 FLAIR image showing hyperintensities in T2 weighted Transverse in section showing midbrain,bilateral thalami hyperintensity involvement of Midbrain sparing

Red Nucleus

.Carotid Artery Doppler:
Soft Plaque in left carotid artery without significant stenosis.

ECG

2D echo : normal

Treatment:
1.Iv methyl prednisolone 1gm /IV was started and continued for 5 days
2.Tab.Ecospirin Av(75/20 mg) /po/OD
3. Supportive treatment
After IV Methylprednisolone Patient improved symptomatically
And objectively her power improved in upper limbs to 4/5 and lower limbs - initially from 2/5 to 4/5 over period of 2-3 days.

This video is taken after Receiving high dose of steriods , Patient was able to walk alone for some distance ,with some difficulty .But there is significant improvement in Power going by objective evidence of muscle power.
LUMBAR PUNCTURE :
Lumbar puncture was done ,

and CSF analysis was sent .

Colur - colorless

Appearance- clear

Total counts - 16cells /cumm

Lymphocytes-100%

Neutrophils - nil

CSF glucose -94mg/dl

Protein- 79mg/dl

Chloride -114mmol/lit

High protien and lymphocyte predominant - suggestive of inflammatory process

Anti NMO antibody levels : Serum Aquaporin levels were sent and came negative

Patient was discharged and continuously followed up.

Patient improved symptomatically and is able to walk alone and able to perform her own activities.

Review MRI was done to look for any new lesions. which showed regression of hyperintense lesions.

Discussion:
1.https://academic.oup.com/brain/article/122/11/2171/377380

1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC490512/

This shows only few percent of people show Neurologic symptoms prior to systemic manifestations, and most commonly they develop within 6months - 1 year ,( range 6 months -3years )

On the other hand, Ikedat7 stressed that the common neurologic features of neuro- Behqet's syndrome were motor impairment especially bilateral pyramidal signs and that the mental changes mainly consisted of loss of emotional control with relative sparing of intelligence and memory.

2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5109654/

We performed a systematic review and meta-analysis of studies on neurosarcoidosis published between 1980 and 2016

We identified 29 articles describing 1088 patients diagnosed between 1965 and 2015. Neurosarcoidosis occurred in 5% of patients with systemic sarcoidosis. Mean age at presentation was 43 years and neurological symptoms were the first clinical manifestation of sarcoidosis in 52%. The most commonly reported feature of neurosarcoidosis was cranial neuropathy in 55%, with the facial and optic nerve most commonly affected, followed by headache in 32%. Pleiocytosis and elevated CSF protein were found in 58 and 63%. MRI of the brain showed abnormalities in 70%. Chest X-ray, chest CT, or gallium-67-scintigraphy showed findings consistent with sarcoidosis in 60%, 70% and 69%, respectively.

3: Isolated neurosarcoidosis presenting as meningitis

https://onlinelibrary.wiley.com/doi/full/10.1002/ccr3.1418

The exact etiology of neurosarcoidosis is unknown and multifactorial, involving genetic predisposition and individual and environmental factors

Exposure to mildew, musty odors, pesticides, and agricultural employment have been associated with the development of sarcoidosis Clinical manifestations of neurosarcoidosis can be found in 5–20% of cases of systemic sarcoidosis, and these symptoms can be mild or severe 5 (Table 2). About half of patients with neurosarcoidosis can present with neurologic manifestations sooner than systemic sarcoidosis is apparent

5: https://sarcoidosisnews.com/2016/07/19/isolated-neurosarcoidosis-difficult-to-diagnose-but-easy-to-treat/
6: https://www.hindawi.com/journals/pri/2012/871019/
Articular involvement is characterized by nonerosive and nondeforming arthritis which often presents with monoarticular pattern, although asymmetrical polyarthritis can occur. The articular involvement is usually transient in nature with episodes lasting from a few days to weeks Parenchymal involvement including brainstem involvement, hemispheric manifestations, spinal cord lesions, and meningoencephalitis is seen in the majority of patients (%80)
Table 6: Summary of evidence-based algorithmic therapy for Neuro-Behcet’s disease.
1^st line.Corticosteroids
2nd line Azathioprine, cyclophosphamide, Anti-TNF-α, IFN-α
3rd line Methotrexate, Anticoagulation
In parenchymal involvement, corticosteroids (100 mg/d or 1 gx 5 days as pulse treatment) should be the first choice. Azathioprine is usually com- bined with corticosteroids. In severe or unresponsive cases, cyclophosphamide can be given additionally [83]. Anti-TNF- α agents and IFN-α are other new effective alternative agents [19]. Methotrexate is another treatment alternative [67, 68].
7. https://www.sciencedirect.com/science/article/pii/B9780702040887001103
Nervous system involvement, known as “neuro-BS” (NBS), is seen in about 5–10% of all cases. Clinical and imaging evidence suggests that primary neurologic involvement in BS may be subclassified into two major forms: the first, which is seen in the majority of patients, may be characterized as a vascular-inflammatory central nervous system disease with focal or multifocal parenchymal involvement, mostly presenting with a subacute brainstem syndrome and hemiparesis (intra-axial NBS); the other, which has few symptoms and a better neurologic prognosis, may be caused by isolated cerebral venous sinus thrombosis and intracranial hypertension(extra-axial NBS), occurring in 10–20% of the cases.

Blog Link: https://2018-21batchpgy3gmpracticals.blogspot.com/2021/08/18100006005-case-presentations.html

CVS

Informant: patient’s daughter

A 58 year old woman presented with the complaints of

Chief complaints: Shortness of breath with exertion since 1 year and at rest since 15 days

Cough intermittently since 4 months

Swelling of both lower limbs on and off since 2 months

Swelling of right lower limb since 10 days

History of present illness: the patient had complaint of shortness of breath since 1 year which was present with farm work started insidiously, progressing over time, exertional, non seasonal, reached the present state of shortness of breath at rest. Associated with increase during sleeping position and relieved during sitting or standing position.

Complaint of cough with expectoration intermittently, associated with worsening of chest pain, not associated with fever, no diurnal variations. Expectorant- whitish to slightly pinkish in colour, not foul smelling, no plugs, no frank blood.

Complaint of bilateral pedal edema on and off since 2 months, pitting present, extending till ankles, equal on both sides.

Not associated with chest pain, dizziness, loss of consciousness, abnormal sensations of heart beat.

Associated with increased frequency of urination since 4 months

Past history: No history of similar complaints before 1 year. History of hospitalisation for 3 times in the past one year. Episodes of hospitalisation associated with worsening of shortness of breath, pedal edema and cough. Each time the patient’s attenders gave history of on and off medication intake.

No history of diabetes, hypertension, bronchial asthma, tuberculosis, jaundice.

No known drug allergies.

Family history: no history of similar complaints in the family. No history of sudden cardiac death in the family.

General physical examination: The patient appears conscious, cooperative, dyspnoea at rest present.

Pulse- rate 86 beats per min

Rhythm- regular, volume- low volume, equal pulses on both sides and in all peripheral areas, no radio radial delay, no radio femoral delay.

Blood pressure- 120/60mm Hg

Jugular venous pressure- engorged vein, pulsation, the patient has hepatojugular reflex

Respiratory rate - 24 cycles per minute

Spo2 - 96% on room air

Pallor- present, no icterus, cyanosis, clubbing, lymphadenopathy.

Pedal edema- present, bilateral pitting type, extending till ankles.

Cardiovascular examination:

Inspection:

No deformity or bulge in the precordium, apical impulse seen in sixth intercoastal space 1cm lateral to the midclavicular line, no diffuse pulsations over precordium, no superficial engorged veins. No scars or sinuses over the skin.

Pulsations seen on the right parasternal region and in the epigastrium.

No prominent pulsations in the aortic, suprasternal area, supraclavicular area, no visible carotid pulsation, no visible pulsations on the back. No kyphosis, scoliosis, drooping of shoulder, winging of scapula.

Palpation:

Apex beat present in the 6th inter coastal space, left sided, 1cm lateral to the midclavicular line over 2 inter coastal spaces. Parasternal heave present on the right parasternal region, obliterated on pressure.

Palpable second heart sound in the pulmonary area, not associated with palpable thrill in the pulmonary area.

No other palpable heart sounds, no thrill in carotid pulse, no superficial veins.

Auscultation:

cardiac rate- about 87 beats per minute Regular in rhythm

Mitral area- soft s1 heard, associated with diastolic murmur mid to late low pitched, no presystolic accentutation, more heard on the left lateral position. No radiation of the murmur heard.

Difficult to appreciate when the patient initially came to the hospital but better audible after initial management.

Pulmonary area- loud p2 heard, no murmur heard, no added sounds

Aortic area- s2 with normal split heard, no murmurs or added sounds heard

Tricuspid area- no murmurs or added sounds heard

Provisional diagnosis- based on the above history and examination the most probable diagnosis is moderate to severe mitral stenosis with frequent acute exacerbations of heart failure.

Blog Link: https://2018-21batchpgy3gmpracticals.blogspot.com/2021/08/18100006009-case-presentations.html

CVS

SHORT CASE:

42 year old male patient came to casuality with chief complaints of bilateral pedal edema (pitting type)(l>r) since 15 days, Fever and SOB since 2 days.

HISTORY OF PRESENT ILLNESS:

The patient was asymptomatic 15 days back until he had bilateral pedal edema(pitting) extending upto shin of tibia.

He had an ulcer over left malleoli 10 days back followed by increased swelling of left lower limb.

From the past two days he complains of low grade intermittent fever with generalized weakness and shortness of breadth (grade 2-3).

HISTORY OF PAST ILLNESS:

Not k/c/o DM, hypertension, asthma, epilepsy, Heart disease or tuberculosis

PERSONAL HISTORY:

He has been consuming alcohol 180ml daily and khaini 2-3 per day for the past 20 years.

GENERAL EXAMINATION:

The patient is conscious

Icterus is present

Pedal edema is present

Absence of pallor, cyanosis, clubbing, lymphadenopathy

VITALS:

VITALS

1.Temperature:- 98.6 F

2.Pulse rate: 110 beats per min

3.Respiratory rate: 18 cycles per min

4.BP: 100/70 mm Hg

SYSTEMIC EXAMINATION:

A.CARDIOVASCULAR SYSTEM:

· S1, S2 heard

· No murmers

· Apex beat visible

· Diffuse shifted down and out

· Palpable p2

· Parasternal heave is present( grade 3)

B.RESPIRATORY SYSTEM:

· Barrel shaped chest

· BAE +

· Crepts + right sided lung fields

BARREL SHAPED CHEST (AP diameter-23 cns, Transverse diameter-23 cms)

C.EXAMINATION OF ABDOMEN: Soft, non tender

D.CENTRAL NERVOUS SYSTEM: No Focal Neurological Deficit

PROVISIONAL DIAGNOSIS:

HFref 2° to CAD b/l PLEURAL EFFUSION

AKI ( ? prerenal ) CRS -1

? ALCOHOLIC LIVER DISEASE

R. LOWER LOBE PNEUMONIA

? COPD

LEFT LOWER LIMB CELLULITIS.

INVESTIGATIONS:

Investigations on 1/7/21:

Chest X-ray ECG-

LIVER FUNCTION TESTS: RENAL FUNCTION TESTS:

Total bilirubin -2.60 mg/dl Serum creatinine -2.1 mg/dl

Direct bilirubin-1.35 mg/dl Blood urea - 81 mg/dl

AST-75 IU/L Serum electrolytes -

ALT-31 IU/L Sodium - 129 mEq /L

ALP- 157 IU/L Potassium -4.8 mEq /L

total proteins-6.1 g/dl Chloride - 94 mEq /L

Albumin 3.5 g/dl

A/G ratio 1.37.

HEMOGRAM: CUE:

hemoglobin -10.3 g/dl ALBUMIN -2+

Total counts -19400 cells /cumm sugars - nil

Neutrophils-92 % Pus cells - 4-6

Lymphocytes -4%

Platelets -1.83 lakhs

Smear -

RBC- microcytic hypochromic

WBC-neutrophilic leukocytosis

PLATELETS -adequate

USG ABDOMEN: 2d Echo -

bilateral pleural effusion -right > left Right atrium, right ventricle, left atrium –Dilated Left ventricle - global akinaesia

Mild ascites EF - 30%

Left kidney - raised echogenicity IVC - dilated

Investigation 1^st day: Investigation 2^nd day:

ecg - atrial fibrillation, irregular RR interval

TREATMENT :

Treatment:

1) Fluid restriction <1lit/day

2) salt restriction. <2gm/day

3) Inj. ceftriaxone 1gm IV/BD

4) tab LASIX 40mg BD (8am to 4pm)

5) Tab MET-XL 25mg BD

6) Tab AZITHROMYCIN 500mg OD

7) Tab ECOSPIRIN-AV 75/20 mg OD

8) BP PR temp and spO2 monitoring

9) tab DIGOXIN 0.25 mg stat

10) Inj. CLINDAMYCIN 600mg IV/TID. 5 days

Blog Link: https://2018-21batchpgy3gmpracticals.blogspot.com/2021/08/18100006008-case-presentations.html

ENDOCRINE

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.

- Loss of libido and erectile dysfunction since 2 months .

Pt was apparently alright one and half year ago , when he slowly developed erythematous round leisons which are annular shaped and itchy all over abdomen , upper limb ,groin and inner thigh region.

No history of fever back then. No other complaints apart from skin lesions.

Pt visited local RMP where he prescribed auyurvedic medications and other creams ( unknown composition as pt don't have them currently ). He also prescribed tablets (unknown composition) . Patient started using all these medications for 1-2 months.

Leisons reduced a bit after using medications.

Later after 2 months he developed multiple hyper pigmented plaques over lower limbs ,abdomen , for which he again visited same place and used ayurvedic oils over the leisons.

He also used clobetasol ointment over the leisons.(for approximately 1 year all over the body)

He started noticing pink striae over his abdomen first and later on back and over arms,which were gradually increasing in size.Later he visited a hospital and used miconazole and luliconazole ointments also.

He used clobetasol ointment all over the leisons for long time.

He started noticing abdominal distension and facial puffiness ,weight gain, but never visited any hospital.

Later he developed pedal edema and low back ache since 3 months.

His consulted a dermatologist at this point of time who advised to consult physician and prescribed monteleukast , itraconazole tablets ,luliconazole ointment for tenia corporis.

He stopped all medications one month ago and visited our opd with complaints of pink striae and easy fatigue ,weakness and low back ache.

His brother also gave history of pt being moody and feeling of low self esteem due to multiple leisons.

He even complaints pt wouldn't step out of house and always stays indoor and wouldn't interact with others.

ALLERGIC HISTORY - pt gives h/o allergy to eggs ,brinjal .

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 .

.Skin examination - Multiple itchy erythematous annular leisons noted all over abdomen , upper limb ,groin and inner thigh region .

Multiple hyperpigmented plaques noted over bilateral lower limbs .

SYSTEMIC EXAMINATION :

CVS - S1S2 heard .No murmurs

RS - BAE present .

No adventitious sounds .

P/A - Soft , distended .

No organomegaly .

Bowel sounds present.

CNS - HMF - INTACT R. L

MOTOR SYSTEM - POWER - UL 5/5 5/5

LL 5/5 5/5

Proximal muscles lower limb - power is 4/5 .

TONE - NORMAL.

REFLEXES - B. T. S. K. A. P

R. +2 +2. +1. +2. +1. FELXOR

L. +2. +2. +2. +2. +1. FLEXOR.

CRANIAL NERVES - NORMAL .

Difficulty in getting up from chair was noticed.

PROVISIONAL DIAGNOSIS -

? IATROGENIC CUSHINGS SYNDROME .

TINEA CORPORIS .

DENOVO HTN .

INVESTIGATIONS : RBS - 139 mg/dl

CBP - HB - 13.4 g/dl

TLC - 6,800

PLT - 1.5 lakhs.

CUE - ALBUMIN - +1

SUGARS - NIL .

PUS CELLS - 3-4

RBC - NIL .

LFT - TB -1.03 RFT - UREA - 22

DB-0.21 SERUM CREATININE -0.6

ALBUMIN - 3.9 ELECTROLYTES - NA - 136

K- 4

CL-98

ECG - SINUS TACHYCARDIA USG ABDOMEN – NORMAL

LVH PRESENT.

This was picture of striae one year ago when it gradually started :

On presentation to opd pictures 1 year back

We took dermatologist opinion for tenia corporis where they advised

Ointment AMLORFINE

FUSIDIC ACID CREAM.

SALINE COMPRESS OVER LEISONS.

Plan to start anti fungals on next visit once dose of steroids is reduced .

OPTHAL opinion Was taken to look for visual acuity and cataract .

No features of lens opacities noted .

BUT IOP was high ,where they advised to follow up .

We advised pt to get fasting 8am serum cortisol levels and was planned to start on low dose steroids to avoid adrenal crisis.

8AM S CORTISOL LEVELS (30/5/21)

- 0.46 mcg/dl ( very low) .

( normal range - 4.3-22.4 mcg/dl).

In view of lvh pt was started on tab telma 20 mg od .

On 3/6/21 - ACTH STIMULATION TEST WAS DONE .

BY INJECTING 0.4 ML OF ACTOM PROLONGATUM INJECTION (ACTH) INTRA MUSCULAR @ 7am

1 HR LATER FASTING SERUM CORTISOL SAMPLE WAS SENT .

VALUE - 0.73 mcg/dl

Indicating there was HPA AXIS suppression and pt was started on TAB HIZONE 15 mg per day in three divided doses @ 8am ,12 pm and 4 pm.

Pt was asked to follow up after one month .

ON NEXT VISIT 1 month back.

Pt was symptomatically better , pedal edema subsided.

Striae were pale in color and we're subsiding.

Weight - 67kg

Ht -175 cm.

Bp- 160/100 mmHg.

Pr -88bpm.

Dose of Tab hizone was reduced to 10 mg per day in divided doses for one month.

In view of low back ache Xray LS spine was done which was normal and pt was advised.:

Tab Shelcal 500 OD and Tab Vit D 3 Od.

Tab ULTRACET /PO/SOS.

Psychiatry opinion was taken and he was diagnosed with moderate depression.

In July 2021 pt was complaining of fever ,sore throat and dry cough since 3 days and he was tested positive for COVID 19 , we advised him home isolation and PCM 650 Mg /po /sos .

He was advised to continue tab hizone tablets as it was advised.

He recovered within one week .

Next visit : ( 6/8/21).

BP- 170/100 - TELMA DOSE WAS INCREASED TO 40 MG OD.

PR - 88bpm.regular , normovolemic.

Wt- 69 kg

Height -

Abdominal girth - 96cm

Pt complaints of excoriation over striae and appearance of erythematous macules over abdomen whenever he takes food he is allergic to.

Took dermatologist opinion for it . They started him on Tab Itraconazole 100 mg bd. And lulifin cream and tab levocitrixine 5mg od.

His brother complaints of depressed mood , pt not going out due to social stigma. Psychiatric counselling was given .

He still complaints of low back ache..othropedics opinion was taken and advised to continue Ultracet and tab Shelcal .

Cbp , cue and electoltes were repeated which were all in normal range .

USG ABDOMEN was done - Normal kidney size bilateral and CMD maintained. No other sonological abnormality noted.

As his lesions dint subside we reduced dose of hisone to 7.5 mg per day ,to see response.

At this point of time we are now in diagnostic dilemma whether endogenous CUSHINGS is also present in this patient , as he is responding slowly to treatment .

We advised him to review after 15 days to see progress . And accordingly plan to evaluate further to rule out endogenous CUSHINGS SYNDROME.

FINAL DIAGNOSIS:

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

TINEA CORPORIS

DENOVO HTN .

Blog Link: https://2018-21batchpgy3gmpracticals.blogspot.com/2021/08/18100006003-case-presentations.html

GIT

LONG CASE:

A 47 year male patient resident of Nalgonda came with chief complaints of abdominal distension and swelling of bilateral lower limbs since 6 months which is gradually increasing since 10 days and fluid discharge from the umbilical area since 2 days and fever since 2 days.

History of present illness

Patient was apparently asymptomatic 18 months back then he noticed abdominal distension which is insidious in onset and gradually progessive in nature and subsequently noticed bilateral swelling of lower limbs , he was hospitalized for one week and took medication which increased his urine output and abdominal paracentesis was done and felt better ,, However he discontinued medicine 6 months back and presented with similar complaints where he was hospitalized and treated conservatively , he was hospitalized 3 months back again with similar complaints , again abdominal paracentesis of 1.5 to 2 lit was done. He is on medication ,

the past 10 days he noticed abdominal distension associated associated with swelling of bilateral lower limbs which started at ankle and progressed upto knee ,

C/0 of swelling over umbilical region since 3 months insidious in onset , progressive in nature initially of pea nut size now progressed to size of 3* 4 cm where he stratched it and clear yellow fluid started oozing from last 2 days it and it is not associated with blood.

H/0 of fever high grade, intermittent in nature not associated with chills, since 2 days,

H/0 of anorexia, fatigue and generalized weakness since 3 months,,

H/0 of itching present since 3 months, which generalized in onset more on the trunk,,

H/0 of disturbed sleep since one month, where he complained of excessive day time sleepiness and night distured sleep,

H/0 of yellowish discoloration of eyes 3 months back now it subsided,

Past medical illness-

History of abdominal distension , swelling of bilateral pedal oedema, and hematemesis one episode 50 ml 18 months back ,where he admitted in an hospital for 10 days which relieved with diuretics , abdominal paracentesis and gastric oesophageal ligation was done.

Appendicectomy 25 years ago

No history of hypertension, diabetes, thyroid , epilepsy or seizure disorder.

Personal history-

Diet - mixed

Sleep - disturbed , excessive day time sleep , night time disturbed sleep since one month.

Appetite- decreased.

Bladder habits- regular and normal.

Habits- chronic consumption of alcohol since 20 years daily , country liquor of 500 ml nearly 110gm per day, and whisky of 150 ml per day nearly 50gm per day,

Last binge of alcohol - 3 days before admission he took 100gm.

Summary - Decompensated chronic liver disease secondary to ethanol consumption, with ascites, portal hypertension, hepatic encephalopathy stage 1 and spontaneous bacterial peritonitis.

General examination -

Moderately built and nourished.

Patient is oriented to time , place and person.

GCS - E4 V5 M6

VITALS -

Pulse - 82 beats per minute, regular normal volume ,and character, no radio radial or radio femoral delay.

Blood pressure - 100/70 mm Hg, right arm supine position.

Respiratory rate - 18 cpm, thoracoabdominal.

Spo2- 98 % on room air

Jvp - not elevated.

Physical examination-

pallor - present

Icterus - absent

No cyanosis

No clubbing

No generalized lymphadenopathy

Pedal edema +

Head to toe examination-

Axillary and public hair - sparse.

B/ l parotid enlargement - negative

Flapping tremors - seen.

Inspection -

Oral cavity - No dental caries and no Tobacco staining

Abdomen - flanks full, distension.

Umbilical hernia present

Appendicectomy scar present.

Distened veins present.

No visible peristalsis or no visible pulsations.

Palpation -

Done in supine position with Both Limbs flexed and hands by side of body.

No tenderness or local rise of temperature.

Abdomen - soft.

No gaurding and rigidity

Lower border of liver not palpable.

Spleen not palpable

Kidneys bimanually palpable , ballotable.

Fluid thrill - present

Abdominal girth - 98 cms .

Xiphisternum to umbilicus - 16 cms

Public symphysis to umbilicus - 13cms

Percussion -

Liver span - upper border of liver dullness in 5 th intercoastal space in mid clavicular line, lower border could not be appreciated.

Auscultation:

Normal bowel sounds heard.

No hepatic bruit , venous hum or friction rub.

Examination of external genitilia - No testicular atrophy.

Examination of spine - Normal.

Provisional diagnosis -

Decompensated chronic liver disease

Etiology - chronic ethanol related.

Ascites , SBP, Hepatic encephalopathy

? Hepatorenal syndrome. Esophageal gastric ligation bands were.

CTP SCORE - C

MELD SCORE - 28.

Investigations-

CBP - CUE -

HB - 10.7 Albumin- 2+

TLC - 19100, Sugar- nil

PLT - 1.50 LAKH Rbcs- nil

N – 90 Pus cells - 4-5

RFT - LFT -

Blood urea - 116 mg/ dl Total bilirubin - 1.63 mg/ dl

Serum creatinine - 4.8 mg/dl Direct bilirubin - 0.40mg/dl

Sodium - 128 meq/l SGOT - 34 IU/L

Potassium - 5.5meq/l SGPT - 20 IU/L

Chloride - 102 meq/l ALP - 186 IU/L

Uric acid - 5.0 Total protein - 5.4 gm/dl

Calcium - 9.1 Albumin - 2.06 gm/ dl

Phosphorus - 8.0

RBS- 70mg/dl

Ascitic fluid analysis -

SAAG - 1.74. Serumalbumin - 2.01

Ascitic albumin - 0.36

Ascitic LDH - 120 IU/ L

Ascitic sugar - 52 mg/ dl

Ascitic protein - 0.8 g/dl

Appearance - Clear

Neutrophil count - 405.

Total count - 675

RBCS - Present.

PT - 16 Sec.

APTT - 32sec.

INR - 1.11

Hiv - negative.

Hbsag -negative.

Hcv - negative.

ECG - Chest X-Ray PA

Blog Link: https://2018-21batchpgy3gmpracticals.blogspot.com/2021/08/18100006001-case-presentations.html

GIT

SHORT CASE -

A 60 years old female presented to the casualty with complaints of fever associated with chills and abdominal pain.

CHIEF COMPLAINTs

➤Fever for the past 6 days.

➤Pain abdomen for the past 3 days

HISTORY OF PRESENTING ILLNESS

Patient was apparently asymptomatic 6 days ago after which she developed high grade fever associated with chills, insidious in onset, progressive, not subsiding with medication, continuous type

Pain abdomen , sudden in onset, pricking type, in the epigastrium and right hypochondrium which gets aggravated on right lateral position and relieved with sitting posture, associated with nausea and reduced appetite, no association with intake of fatty food

HISTORY OF PAST ILLNESS

Not a known case of hypertension, diabetes, bronchial asthma, epilepsy.

k/c/o tuberculosis and took complete treatment.

No history of similar complaints in the past.

DRUG HISTORY

➤No significant drug history or intake of toxins.

PERSONAL HISTORY

➤Occupation: Daily waged labor working in Cotton fields.

➤Patient is married

➤Patient takes mixed diet but has a decreased appetite.

➤Bowel and bladder movement is normal and regular.

➤occasional Alcoholic , non smoker.

- sound sleep

FAMILY HISTORY

➤No significant family history.

MENSTRUAL HISTORY:

G 3 P 4 L 4 A 0

Attained menarche at the age of 20 years, with good flow and volume.

Attained menopause at age of 42 years.

SUMMARY:

60 year old female with high grade fever and abdominal pain confined to

right upper quadrant ,acute in onset, without any alcohol history .

Possibly case of

1) Acute Liver injury (?infective etiology)

2)Acute Cholecystitis.

GENERAL EXAMINATION

Patient is well built, well nourished.

➤Pallor : Not seen

➤Icterus : Not seen

➤Cyanosis : Not seen

➤Clubbing : Not seen

➤Lymphadenopathy : Not seen

➤Edema : Not seen

- No signs of chronic liver cell failure

- No signs of nutritional deficiency.

VITALS

➤Temperature : 101℉

➤PR : 108 beats per minute

➤BP : 100/70 mmHg

➤RR : 24 cycles per minute

➤SpO2 : 95% in room air

➤Blood Sugar (random) : 100mg/dl

SYSTEMIC EXAMINATION

ABDOMINAL EXAMINATION

INSPECTION

➤Shape - Scaphoid, with no distention.

➤Umbilicus - Inverted

➤Equal symmetrical movements in all the quadrants with respiration.

➤No visible pulsation,peristalsis, dilated veins and localized swellings.

PALPATION

➤SUPERICIAL :Local rise of temperature in right hypochondrium with tenderness

and localised guarding and rigidity.

➤ DEEP : Mild enlargement of liver, regular smooth surface , rounded

edges soft in consistency, tender, moving with

respiration non pulsatile

➤No splenomegaly

➤Abdominal girth : 78cms.

➤xiphesternum to umbilicus distance was equal to umbilicus to pubic distance.

PERCUSSION

➤Hepatomegaly : liver span of 16 cms with 4 cms extending

below the costal margin

➤Fluid thrill and shifting dullness absent

➤puddle sign absent

➤Traubes space : resonant

AUSCULTATION

➤ Bowel sounds present.

➤No bruit or venous hum.

NO LOCAL LYMPHADENOPATHY

PER VAGINAL AND PER RECTAL EXAMINATION : NAD

CARDIOVASCULAR SYSTEM EXAMINATION

➤s1 and s2 heard

RESPIRATORY SYSTEM

➤Normal vesicular breath sounds heard.

➤Bilateral air entry present

CENTRAL NERVOUS SYSTEM EXAMINATION

➤Conscious and coherent

PROVISIONAL DIAGNOSIS :

ACUTE HEPATITIS (? INFECTIVE)

INVESTIGATIONS :

DAY 1

Serum Na+ 126 LFT : TB 2.45

Serum K+ 4.7 DB 1.59

Serum Cl- 92 SGPT 10

Serum Creatinine 0.8 ALP 191

Blood urea 40 ALB 2.5

CUE normal PT/INR 17/1.2

CBP : HB 10.7 APTT 33SECS

TLC 13900

PLATELET 4.02L BLOOD CULTURES Showed no growth

USG REPORT IMPRESSION-

Multiple liver abscess with largest measuring 5*5 cms in the 7th segment of liver , with 40 to 50% of liquefaction , hepatomegaly with liver span of 18.5 cms

CT SCAN

Chest X-Ray post Tb Changes

FINAL DIAGNOSIS :

MULTPLE PYOGENIC LIVER ABSCESS WITH ACUTE LIVER FAILURE.

TPR CHART

Blog Link: https://2018-21batchpgy3gmpracticals.blogspot.com/2021/08/18100006010-case-presentations.html

MUSCULOSKELETAL

A 44 year old man presented with a 3-day history of bilaterally symmetrical rapidly progressive generalized edema.

Present Illness

An agile stonemason, the patient reported that this symptom first started suddenly 3 days ago, at night, when he noticed he started feeling facial puffiness with pedal edema. The next morning, while brushing his teeth, the patient noticed he had facial puffiness, in the mirror. At the same time, he also noticed that he developed bilaterally symmetric, pitting type pedal edema, extending upto the middle of his legs. He immediately presented to the hospital with these complaints.

On interviewing the patient further, he denied having breathlessness, palpitations or chest pain. He reported frothing of urine but no haematuria. He also reported gradually decreasing urine output over the past 3 days. He did not have pain during micturition, no pus or any other abnormal discharge (casts) in urine. He did not have any history of vomiting or diarrhea, no history of acute retention of urine, no prior history of fever or rash, no history of antibiotic usage or any drugs in the past 1 week. The patient also denied any history of yellowish discoloration of skin or sclera.

Prior to this, the patient reported that since 2011, he had severe joint pains, which were initially asymmetric and gradually became bilaterally symmetrical and involving the small joints of his hands and wrist. The joint pains were associated with significant local edema, and painful limitation of movements, which made his job (stonemasonry) difficult.

[Other activities which were painful and difficult for the patient were -

Holding his cup of tea or glass of water,

Pain in his finger joints and wrist while brushing,

Pain while holding mug when taking bath and

Pain in toes and ankles on both sides when walking)]

He reported that he also had debilitating early morning pains and limitation of movements in his hands, wrists and feet, which usually lasts for about an hour, He reported that the pains and limitation of movements improved with activity, with gradual reduction in edema of joints.

From 2011 to 2019, these joint symptoms gradually progressed in severity, now also involving several large joints (shoulders, elbows, knees and hips) warranting several medical consults, where he was frequently prescribed pain killers. The patient did not have any documentation of the pain killers he took in these 8 years. In December 2020, he presented to our hospital with similar complaints of joint pains, when he was prescribed with Etoricoxib and Febuxostat (he had hyperuricemia). He reported that his symptoms alleviated with these drugs but he intermittently had worsening of same symptoms in the interim. The patient denied any history of skin rash, photosensitivity, nasal or oral ulcers, chest pain or abdominal pain, weakness in his limbs (such as difficulty in taking stairs or lifting heavy stones and nor any weakness in his distal aspects of limbs such as mixing food, buttoning his shirt or holding a glass or slipping of footwear), isolated single joint pain or edema, or a past history of kidney stones. He also does not have any history of difficulty in swallowing, altered bowel habits, pain in the pulp of his digits, or painful tearing, photophobia or visual loss. He also denied any history of gritty sensation in eyes or dryness of mouth.

Apart from these, the patient reported that, for the past 3 days, he has burning sensation in his eyes with increased tearing but no visual deficits. He also reported for the past 1 year, he developed subcutaneous swellings in the proximal joints of his fingers. He denies any history of early satiety or post prandial fullness or pain. He reported that his clothes have slightly loosened over the past 1 year with involuntary weight loss and loss of appetite. He denies having a history of wrist or foot drop, chest pain, palpitations or breathlessness. No history of loss of consciousness, falls or tingling or numbness in his feet or hands.

Past History

No significant past history.

Medical/Surgical History

Chronic intermittent use of analgesics (type and dose unknown). Has been using Etoricoxib 60 mg and Febuxostat 80 mg intermittently for the past 8 months. No relevant surgical history. No history of allergy or atopy.

Personal History

The patient had been working as a stonemason for the past 20 years. He is a devout Catholic Christian and a strict teetotal (has never smoked or consumed alcohol in his life). He stays with his wife and 2 children (elder son and younger daughter) in Miriyalguda. He is from a close-knit family and regularly socialises with his family (parents and his 2 elder brothers). Apart from his troubling joint pains, he used to a have a fairly balanced and good quality of life, with good sleep every night, good appetite and adequate access to nutritious food and clean drinking water. He also had a balanced social well-being with a tightly-knit community at home and his church.

However, since the last 1 year, his appetite started to decrease and he also involuntarily lost weight. His bowel and bladder habits have always been normal but these joints pains have forced him into early voluntary retirement from his job in 2019. His and his family's finances have been supported by his brothers and from generous donations from his church. He feels his mental health has remained intact, thanks to his supportive family and fellow churchgoers.

Family History

No significant family history reported.

Social & Educational History

Married for 18 years with 2 children. Primary education upto Class 7 in Telugu medium.

Immunization History

None taken since birth.

Problem Representation / History Analysis

A 44 year old stonemason from Miriyalguda, presented with a 3 day history of anasarca, frothy urine and gradually decreasing urine output, on a background of a 10 year history of chronic bilaterally symmetric polyarthritis (evidenced by severe pain, edema and limitation of joint movements).

Localisation of Acute Problem

Anasarca and frothy urine with decreasing urine output suggest a renal pathology. Proteinuria causing anasarca likely due to glomerular pathology. Other systemic causes like heart failure and liver dysfunction can be ruled out due to absence of dyspnea, palpitations, bendopnea or syncope. Liver dysfunction can be ruled out by lack of jaundice, melaena or hematemesis (from bleeding varices), and abdominal distention not occurring prior to pedal edema.

Within the kidney, pre-renal and post-renal causes can be effectively ruled out from the absence of volume loss (vomiting, diarrhea, diuretic abuse or burns) and no history of acute retention of urine or lower urinary tract symptoms (LUTS) like frequency, urgency, hesitancy or precipitancy. The presence of frothy urine and edema strongly supports a glomerular pathology due to significant loss of protein and also decreased urine output. Isolated defects in tubular/interstitium are unlikely as such patients have a deficit in maintaining urinary concentration, which causes polyuria. Such a high range of proteinuria causing anasarca is also not seen with tubular/interstitial pathologies alone.

Provisional Diagnosis - Acute Glomerulopathy (Glomerulonephritis / Nephrotic syndrome)

Features to look for -

1. Hypertension (secondary hypertension in Glomerulonephritis)

2. Haematuria on Urine Microscopy (particularly dysmorphic RBCs in urine)

3. Quantification of Proteinuria

4. Serum Albumin / Total Proteins

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

6. Renal biopsy, if diagnosis remains uncertain

Localisation of Chronic Problem

This 44 year old man has a 10 year history of bilaterally symmetrical progressive inflammatory polyarthritis. Features favouring an inflammatory pathology are -

1. Features of inflammation such as severe pain associated with edema of the joints and limitation of range of active movements

2. Early morning stiffness, lasting for more than 30 mins (for 1 hour in this patient)

3. Pain and edema of joints improving with activity and worsening with rest

4. Features of uncontrolled systemic inflammation such as fever, involuntary loss of weight associated with loss of appetite.

5. Swellings at joints and deformation of normal joint posture

Provisional Diagnosis - Bilaterally Symmetric Chronic Progressive Inflammatory Peripheral Polyarthritis

Clinical Examination

Initial examination revealed, the patient was conscious, coherent and co-operative, lying in bed in supine position. He was in some visibly apparent distress with flexion at his elbows and wrists, bilaterally, which were mildly painful when resting on the bed and his abdomen, respectively. The patient was dressed in a round neck t-shirt and when asked to sit up and take his t-shirt off, he had significant pain and limitation of movements at multiple joints but no weakness.

Vitals were taken in supine and sitting position -

Supine Position

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)

Sitting Position

Pulse - 96 bpm, regular, normal volume, condition of vessel wall - normal, no radio-radial or radio-femoral delay.

Head to Toe General Examination

General Condition - Fair built and appears well nourished.

Hair - Thin and slightly greyed. Not easily pluckable or no areas of scarring or non-scarring hair loss. No lesions noted on the scalp.

Eyes - No conjunctival chemosis or injection, No redness or corneal lesions. Bilateral, purplish reticular markings noted on the sclera of both eyes. Palpebral conjunctival pallor +. No icterus. No cyanosis. Bilateral Periorbital puffiness +

Periorbital Edema +. Pallor was also +

General Head, Neck & ENT - No abnormalities. No lymph node enlargement.

Axial - No apparent spinal deformities

Fingers and Nails - Leukonychia +. No clubbing or cyanosis. Capillary refill time - 2 seconds.

Bilateral pitting type pedal edema +, extending upto middle of legs.

Systemic Examination

Musculo-Skeletal System

Axial Skeleton

Inspection - No visibly apparent spinal deformities;

Palpation - Inspectory findings confirmed. No spine tenderness.

Movements - Atlanto-occipital - Flexion, extension and lateral flexion normal

Atlanto-axial - Rotation of head normal

Spinal Flexion, Spinal Extension, Lateral Flexion and Rotation are normal

Appendicular Skeleton - Upper Limbs (Positive Findings)

Shoulders (both sides) -

- Inspection - Attitude - Slightly flexed and internally rotated; Contour normal; No edema or erythema

- Palpation - Mild increase in temperature on both sides

- Range of Movements - Mild Active and Passive limitation of all range of movements (flexion, extension, adduction, abduction, internal rotation and external rotation)

Elbows (both sides) -

- Inspection - Attitude - mid-flexion; alignment of elbow and forearm - normal; Edema + ; No scars or sinuses; no muscle wasting

- Palpation - All Inspectory findings are confirmed; Raised temperature +; Edema +; Wincing on touch + ; Fluctuation test + ; 3 point bony relationship intact

- Range of Movements - Severe pain on active movements of flexion, extension; Mild pain with supination and pronation;

Wrists (both sides) -

- Inspection - Attitude - Mild extension; Radial deviation of wrists +; Diffuse edema +; Redness +;

- Palpation - All Inspectory findings confirmed; Temperature raise +; Wincing on touch +;

- Range of Movements - Severely limited and extremely painful active movements of flexion, extension, radial deviation and ulnar deviation.

Hands (both sides) -

- Inspection - Attitude - Palmar subluxation and Ulnar deviation of the MCP joints; Swollen and Erythematous PIP joints; No swelling or redness of DIP joints; No apparent muscle wasting; Mild hyper-extension of PIP of thumbs; Pulp of fingers normal

- Palpation - All Inspectory findings are confirmed; Temperature raise +; Wincing on gentle palpation of MCP joints and PIP joints; Palpation of DIP joints is normal; Swellings also + on 3rd and 4th PIP joints on both sides. Z-deformity +.

- Range of Movements - Severe pain and severe limitation of active movements of flexion, extension and ulnar and radial deviation of MCP joints; severe pain and limitation of active and passive movements of flexion and extension at PIP joints. DIP joints normal.

Appendicular Skeleton - Lower Limbs (Positive Findings only)

Hip Joints (both sides)

- Limitation of passive movements of flexion and extension (towards the end of range of motion);

Knee Joints (both sides)

- Inspection - Swelling and erythema + ; Attitude - flexion;

- Palpation - All Inspectory findings are confirmed; Raised temperature + ;

- Range of movements - Severe pain and limitation of active and passive movements of flexion and extension and lateral and medial rotation; (Patient was unable to stand on Day 1 and was able to stand on Day 2 with analgesic use).

Ankles (both sides)

- Mild pain and limitation of active and passive movements of plantar flexion and dorsiflexion; Mild pain and limitation of movements of inversion and eversion.

- Palpation of Achilles tendon is normal.

Foot examination (both sides)

- Mild pain and limitation of passive movements of flexion and extension of MTP joints; great toe flexion and extension normal;

Other Systems Examination

Cardiovascular System - No abnormalities detected

Respiratory System - No abnormalities detected

Abdominal Exam - No abnormalities detected

Nervous System - No deficits detected

Investigations

X-ray AP view of the hands and wrists - Osteopenia and erosions of the MCP and PIP joints are noted. Scallop sign +. Significant soft tissue swelling is also noted.

Chest X-ray PA view - Full inspiratory, underexposed film with no malrotation or angulation. Bones - Clavicle, Head of Humerus, Coracoid process and acromion of scapula appear normal. The ribs are normal. No mediastinal lymph nodes or enlargement. The right heart border shows mildly dilated right atrium. The left heart border shows a prominent aortic knuckle, the pulmonary bay area is normal, the left atrial appendage appears normal and the left ventricular free wall also appears normal. The bronchovascular markings are also prominent, likely due to underexposure.

Standard 12 lead ECG with normal voltage and speed @ 25mm/s; P waves, QRS complexes and T waves have normal morphology and duration; P-P and R-R intervals are normal. PR and QTc intervals are normal.

Blood work from previous presentations to hospital. RA factor was negative

24hrs urinary protein: 1500 mg

24hrs urinary creatinine: 0.8

Urine Microscopy - Freshly voided urine sample was centrifuged at high speed (> 2700 RPM) and sediment collected and fixed on glass slide and examined under microscope at 400 (10x * 40x) showed DYSMORPHIC RBCs (black circles) and occasional pus cells (red circles). Dysmorphic RBCs were those that had altered shape, microcytic or with membrane defects.

Diagnostic Approach

With a provisional diagnosis of Acute Glomerulopathy on the background of bilaterally symmetric chronic progressive erosive peripheral polyarthritis, features supporting the diagnosis of glomerulonephritis were -

- Secondary Hypertension

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

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

- Dysmorphic RBCs in Urine

(A review of literature was done to evaluate the sensitivity and specificity of dysmorphic RBCs for glomerular disease pathologies - One study conducted in Bangladesh showed that urinary dysmorphic RBCs were 92.7% sensitive and 100% specific for a biopsy confirmed diagnosis of glomerulonephritis. [1]

Similar values of sensitivity and specificity was also confirmed in another study jointly conducted in Australia and China, where glomerulonephritis was confirmed with renal biopsy. [2] )

Thus, with glomerular disease being most likely, an anatomical diagnosis is made. The etiological cause for glomerular injury needs to be ascertained.

A careful construction of the problem representation for this patient and insight into the sequence of his life events can provide clues that the current acute problem could be a sequelae of his long term, poorly treated chronic problem.

Thus, a good clinical diagnosis of his musculo-skeletal problems is required to get a better picture of his current illness.

The patient has Bilaterally Symmetrical Chronic Progressive Erosive Peripheral Polyarthritis. Differential diagnosis for such conditions include -

Rheumatoid Arthritis (most likely)
Rheumatoid Arthritis with coexistent Gout
Psoriatic Arthritis
Enteropathic Arthritis
Reactive Arthritis
SLE
Polymyositis / MCTD (Mixed Connective Tissue Disorder) (least likely)

With Rheumatoid Arthritis being most likely, ACR/EULAR classification criteria can be applied for diagnosis -

This patient has >10 joints involved with multiple small joints involvement - 5 points; Symptom duration 10 years - 1 point; RA Factor - NEGATIVE; CRP elevated & ESR - 120 mm/hr - 1 point; Total Score - 7/10 [3]

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

Pedagogic Questions

Abdominal fat pad biopsy vs Renal biopsy ?

The clinical data and biopsy results of 194 SA patients who were treated in Peking Union Medical College Hospital from January 2009 to June 2015 were retrospectively analyzed. Results The highest sensitivity was achieved by biopsy of affected organs,with renal biopsy 97.4%,heart biopsy 95.0% and liver biopsy 87.5%. Among non-invasive biopsy methods,tongue biopsy was found to be 75% sensitive,followed by gingiva biopsy at 57%,abdominal fat pad aspiration at 57%,rectum biopsy at 16%,and bone marrow examination at 8%. Combination of tongue and abdominal fat pad biopsy yielded a detection rate of 93.1%. Conclusions Biopsy of the involved organ has the highest sensitivity. However,combination of multiple non-invasive biopsy methods may has sensitivity comparable to organ biopsy and is safer and more convenient. [7]

2. Single DMARD vs Combination therapy ?

A Cochrane review, published in The BMJ [8] looked at the clinical efficacy of Methotrexate monotherapy vs Combination therapy (MTX + Non-biological or MTX + Biologicals). Data of Methotrexate -naïve patients was gleaned from this meta-analysis -

Outcomes - The major outcomes of the review were American College of Rheumatology (ACR) 50 response, a composite measure of improvement in disease activity (dichotomous outcome); radiographic progression, measured by Larsen, Sharp, or modified Larsen/Sharp scores (continuous outcome); and withdrawals due to adverse events, including death (dichotomous outcome).

3. When to initiate dialysis ? How long can we wait ?

Ex tempore interpretation of the AKIKI-2 trial. [9]

4. Can Rheumatoid Arthritis and Gout co-exist together ?

The study population included 813 patients, 537 (66%) were rheumatoid factor positive; 33% had rheumatoid nodules, and 53% had erosive joint disease. During 9771 total person-years of follow-up (mean 12.0 years per RA patient), 22 patients developed gout by clinical criteria. The great toe was the most common site of gout (12 of 22 patients). The 25 year cumulative incidence of gout diagnosed by clinical criteria was 5.3%. Typical intracellular monosodium urate crystals were present in 9 of 22 patients with acute gout; all had developed gout after the RA incidence date. The 25 year cumulative incidence of gout diagnosed by clinical criteria including presence of urate crystals is 1.3%. The prevalence of gout in RA on Jan 1, 2008 was 1.9% (11 of 582 patients) as opposed to expected prevalence of 5.2% (or 30 patients) based on National Health and Nutrition Examination Survey (NHANES) data using age and sex specific prevalence rates. [10]

References

Sultana T, Sultana T, Rahman MQ, Rahman F, Islam MS, Ahmed AN. Value of dysmorphic red cells and G1 cells by phase contrast microscopy in the diagnosis of glomerular diseases. Mymensingh Med J. 2011 Jan;20(1):71-7. PMID: 21240166.
Pollock C, Liu PL, Györy AZ, Grigg R, Gallery ED, Caterson R, Ibels L, Mahony J, Waugh D. Dysmorphism of urinary red blood cells--value in diagnosis. Kidney Int. 1989 Dec;36(6):1045-9. doi: 10.1038/ki.1989.299. PMID: 2689749.
https://www.eular.org/myUploadData/files/RA%20Class%20Slides%20ACR_Web.pdf.
Helin H, Korpela M, Mustonen J, et al. Renal biopsy findings and clinicopathologic correlations in rheumatoid arthritis. Arthritis Rheum 1995;38(2):242–7.
Korpela M, Mustonen J, Helin H, et al. Immunological comparison of patients with rheumatoid arthritis with and without nephropathy. Ann Rheum Dis 1990;49(4): 214–8.
Horak P, Smrzova A, Krejci K, et al. Renal manifestations of rheumatic diseases. A review. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2013;157(2):98–104.
Zhang CL, Feng J, Cao XX, Zhang CL, Shen KN, Huang XF, Zhang L, Zhou DB, Li J. Selection of Biopsy Site for Patients with Systematic Amyloidosis. Zhongguo Yi Xue Ke Xue Yuan Xue Bao. 2016 Dec 20;38(6):706-709. doi: 10.3881/j.issn.1000-503X.2016.06.013. PMID: 28065238.
Hazlewood GS, Barnabe C, Tomlinson G, Marshall D, Devoe DJ, Bombardier C. Methotrexate monotherapy and methotrexate combination therapy with traditional and biologic disease modifying anti‐rheumatic drugs for rheumatoid arthritis: A network meta‐analysis. Cochrane Database of Systematic Reviews. 2016(8).
Gaudry S, Hajage D, Martin-Lefevre L, Louis G, Moschietto S, Titeca-Beauport D, La Combe B, Pons B, De Prost N, Besset S, Combes A. The Artificial Kidney Initiation in Kidney Injury 2 (AKIKI2): study protocol for a randomized controlled trial. Trials. 2019 Dec;20(1):1-0.
Jebakumar A, Crowson C, Udayakumar D, Matteson E. Co-Existence of Gout in Rheumatoid Arthritis: It Does Happen! A Population Based Study.: 134. Arthritis & Rheumatism. 2012 Oct;64.
Huang X, Du H, Gu J, Zhao D, Jiang L, Li X, Zuo X, Liu Y, Li Z, Li X, Zhu P. An allopurinol‐controlled, multicenter, randomized, double‐blind, parallel between‐group, comparative study of febuxostat in C hinese patients with gout and hyperuricemia. International journal of rheumatic diseases. 2014 Jul;17(6):679-86.

Blog Link: https://2018-21batchpgy3gmpracticals.blogspot.com/2021/08/18100006003-case-presentations.html

RENAL

A 45 year old female patient farmer by occupation Resident of Nalgonda

came to casuality with complaints of vomitings and abdominal pain since 4 days

HISTORY OF PRESENTING ILLNESS

Patient was apparently asymptomatic 6 days back then she was allegedly bitten by snake on her right lateral foot at 7.30 pm while she was cooking, she was taken to local hospital and started on treatment ( 20 min whole blood clotting test was positive started her on Anti snake venom later shifted here ,

C/0 of abdominal pain since 5 days, periumbilical in location, non radiating , pain aggravated with food intake relieved with medications.

C/0 of vomitings since 5

days 3 to 4 episodes per day, containing non digested food particles non bilious , non projectile in nature,

C/0 swelling of right foot non pitting type insidious in onset progressed upto ankle and releived in 2 days

C/0 of anorexia , myalgias, fatigue and generalized weakness from 5 days,

Past history -

No histoy of hypertension , diabetes, thyroid , epilepsy , tuberculosis and asthma.

Personal history-

Diet - mixed

Sleep- adequate

Appetite - normal

Bowel and bladder -

Not a alcoholic or smoker

Summary -

45 year old female patient alleged to snake bite , presententing with Nonoliguric Acute kidney injury.

General physical examination-

Patient was conscious, coherent , well oriented to time place and person

Pallor - present

No Icterus

No clubbing , no cyanosis

No lymphadenopathy

No edema.

Vitals -

Temp - 98.6 F ( measured in axilla).

PR- 82 beats per min, normal in rhythum, character and volume ,no vessel wall thickening , no radio radial or radio femoral delay.

Bp - 140/ 90 mm hg, measured in right upper arm in supine position.

RR- 16 cpm.

Cvs - S1 , S2 heard, no jvp rise, no murmurs heard , apical impulse-

Rs - Non vesicular breath sounds heard, equal bilateral air entry , no added sounds.

P/ A - soft , no tenderness elicited,

No mass felt, No organomegaly . Bowel sounds heard.

CNS -

Higher mental functions are normal.

Tone - normal

power - 5/5 in both limbs,

All superficial and deep reflexes are normal

Sensory and cerebellar system - intact

INVESTIGATIONS-

COMPLETE BLOOD PICTURE-

HB - 8.5 gm/dl.

Platelet count- 63000

WBC count - 9000

RBS- 113mg/dl. Complete urine examination-

Serum creatinine - 7.4 mg/dl. Colour - pale yellow

Blood urea - 166mg/dl. Pus cells - 2-3

BUN - 77.5 Rbcs - nil

Sodium - 124meq/l Albumin - nil

Potassium - 3.9meq/l

Chloride - 75meq/l

Spot urine protein creatine ratio - 0.13 .

Spot urine sodium - 229 mmol/ L .

Bleeding time - 2min 15 secs

Clotting time - 4 min 45 secs.

LFT

Total bilirubin - 1.0 mg/ dl

Albumin - 4.5 gm

SGPT - 34 ( 15- 40)

SGOT - 24

ALP - 90 IU/L

ABG -

PH - 7.403

Hco3- 16.7

Pco2-. 22.1

Spo2- 97.2 %

Urine protein creatine ratio ,- 0.13

Urinary sodium - 229.

X Ray ECG

USG ABDOMEN

KIDNEY SIZE - Normal, increased echotexture and mild perinephric fluid likely inflammation.

Provisional diagnosis -

Acute kidney injury , secondary to acute tubular necrosis , due to snake bite .

Treatment -

1. 4 sessions of haemodialysis

2. Inj zofer 4 mg TID

3. Inj pan 40 mg Od

4. Strict input / output charting.

High dose vs low dose anti snake venom

http://www.ncbi.nlm.nih.gov/pubmed/15633711

Blog Link: https://2018-21batchpgy3gmpracticals.blogspot.com/2021/08/18100006001-case-presentations.html

RESPIRATORY SYSTEM

26 year old male, construction worker by occupation presented to the casualty with the chief complaints of

Fever since 3 months

Cough with expectoration since 2 months

Dyspnea on exertion since 2 months

Vomiting since 2 months

Decreased appetite and weight loss over last 2 months

Dark coloured stools since 2 weeks.

History of presenting illness:-

Patient was apparently asymptomatic 3months back till when he attended his relative function where he consumed alcohol for 2days ( Around 8 beers) following which after 2days he developed high grade fever though not associated with chills & rigors or Night sweats and it subsided with medication for 1 week but from then he's having on & off fever.

The following month he started experiencing productive cough with mucoid expectoration, blood tinged amounting to 2 to 3 cup's per day it's foul smelling . Cough is more in sitting position & slightly relieved by Lying down on bed & It's more during day time than in night.

He also started feeling difficulty in breathing on walking for small distances . It's progressive & currently he has to take a break After walking for 100meters of distance.

He's having 2 to 3 episodes of vomiting daily containing food particles.

He also complains of loss of appetite and unintentional weight loss of around 10 kgs over the past 3 months from 72kgs to 62kgs.

History of black colour stools since 2weeks not associated with mucus or foul smelling.

No h/o chest pain, palpitations, syncopal attacks, profuse sweating, Orthopnea or paroxysmal nocturnal dyspnea

Past history:-

Not a k/c/o Hypertension, Diabetes mellitus, Asthma, epilepsy, Tuberculosis or any heart diseases. No past history of allergies or surgeries.

Personal history:-

Diet- mixed

Appetite- decreased

Sleep-adequate

Bowel & bladder- normal

Occasional alcoholic, Occasional smoker.

Family history:-

No h/o similar complaints in family members

Summary at end of history:-

A 26yr old male who's a construction worker by occupation and who's an occasional smoker presented with persistent fever, cough with blood tinged expectoration and decreased appetite associated with weight loss since 2months and black color stools since past 2weeks and had a history of reccurent hospital visits & intake of medications for these complaints in past 2months with no history of Hypertension, diabetes or any contact with TB.

Differentaial diagnosis:-

Lung consolidation

Lung abscess

General physical examination:-

Patient conscious, coherent, cooperative

Moderately built & moderately nourished.

Height- 165cm

Weight- 55kgs

BMI- 20.2

Temperature - 100.6f

PR - 94bpm, Regular & normal volume, No radioradial or radio femoral delay.

All peripheral pulses felt

BP - 100/70mmhg Right arm supine position

RR - 28cpm, Abdominothoracic type.

Spo2 at 98 % on room air.

Pallor +nt

No Nicotine staining over hand's, lips or any visible wasting of hand muscles

Spine appears normal

SYSTEMIC EXAMINATION:-

RESPIRATORY SYSTEM-

Patient examined in sitting position

Inspection:-

Upper respiratory tract - oral cavity, nose & oropharynx appears normal.

Chest appears Bilaterally symmetrical & elliptical in shape

Respiratory movements appear equal on both sides and it's Abdominothoracic type.

Trachea central in position & Nipples are in 4th Intercoastal space

No signs of volume loss

No dilated veins, scars, sinuses, visible pulsations.

Palpation:-

All inspiratory findings confirmed

Trachea central in position

Apical impulse in left 5th ICS, 1cm medial to mid clavicular line

Cricosternal distance is 3finger breadths.

MEASUREMENTS-

chest circumference- 31 inches at expiration & 32 inches at full inspiration

Chest expansion- 2.5cm

Right left

Hemithorax- 15.5 inches 15.5 inches

Hemithorax expansion- 1/2inch 1/2inch

AP diameter- 7 inch

Transverse diameter- 12 inches

AP/T ratio - 0.58

Respiratory movement's:- decreased on Right side.

https://drive.google.com/file/d/1t2cmYVK6yu6o3VcOhsvibeqqIxISZ8uS/view?usp=drivesdk

https://drive.google.com/file/d/1t41C_0FklIuSHq68BDEh0uEK43_srWWy/view?usp=drivesdk

Tactile vocal phremitus- increased in right Infraaxillary & infra scapular area.

Aegophony & whispering pectorloquy present in right Infraaxillary & infra scapular area

Percussion:-

Right left

Supraclavicular- Resonant (R) (R)

Infraclavicular- (R) (R)

Mammary- (R) Dull

Axillary- (R) (R)

Infra axillary- Dull (R)

Suprascapular- (R) (R)

Interscapular- (R) (R)

Infrascapular- Dull (R)

Auscultation:-

Right Left

Supraclavicular- Normal vesicular (NVBS)

Breath sounds (NVBS)

Infraclavicular- (NVBS) (NVBS)

Mammary- (NVBS) (NVBS)

Axillary- (NVBS) (NVBS)

Infra axillary- Tubular B.S (NVBS)

Suprascapular- (NVBS) (NVBS)

Interscapular- (NVBS) (NVBS)

Infrascapular- Tubular B. S (NVBS)

ABDOMEN :-

Inspection :

shape of abdomen appear normal & symmetrical

No Generalised/Localised distension seen.

All quadrants moving equally with respiration

Umblicus is central & inverted

Skin over the Abdomen- Looks normal

No visible Scars/Sinuses/Dilated/Prominent veins / peristalsis/Pulsations .

Palpation :

All Inspectory findings confirmed

Mild Tenderness in right hypochondrium

No Guarding/ Rigidity

Edge of liver is palpable on deep inspiration Spleen is not palpable

Percussion:-

Liver span is 15cm from right 4th ICS to right coastal margin along mid clavicular line

Spleenic dullness noticed in left coastal margin

Auscultation:-

Normal bowel sounds heard, no renal bruit heard.

CARDIOVASCULAR SYSTEM:-

Apical Impulse felt in left 5th ICS, no parasternal heave or precordial bulge felt

S1S2 heard

No murmers heard.

CENTRAL NERVOUS SYSTEM:-

Higher mental functions intact

No FND, pupils-NSRL.

Cranial nerves- Intact

Motor & sensory systems- Normal.

PROVISIONAL DIAGNOSIS:-

Right lung lower lobe consolidation.

INVESTIGATIONS:-

Hemogram-

Hb- 9gm/dl

Tlc- 13,700cells/cu mm

Plt- 4lakh/cu mm

Rft: Lft:

urea- 10mg/dl Total bilirubin-2.28mg/dl

Creatinine- 0.9mg/dl Direct bilirubin-0.52mg/dl

Sodium-129mEq/l SGOT- 109 IU/L

Potassium-4.1mEq/l                                                                SGPT-12IU/L
Chloride-94mEq/l                                                                   Alkaline phosphate- 313IU/L
                                                                                                Total proteins - 7.5gm/dl
                                                                                                Albumin-2.7gm/d

Esr- 90mm

PT-INR - 20 sec & 1.1

APTT- 39sec

BT & CT - 2min & 5min

HIV, HBSAG, HCV- Negative

ECG Chest X-Ray

USG chest:- Consolidatory changes noted in right lower lobe .

USG abdomen- A large hypoechoeic lesion measuring 8cm × 8cm in right lobe of liver.

CECT abdomen-

Liver abcess with rupture in pleural cavity

Right lung basal consolidation with central

Liquefaction

Final diagnosis:-

Amoebic liver abscess with rupturing into pleural cavity with Right lung basal consolidation.

Initially conservative management is planned

Treatment:-

1. Inj. Metronidazole 750mg/iv/Tid

2. inj.Ceftriaxone 1gm/iv/bd

3. Inj.pantoprazole 40mg/iv/OD

4. inj paracetamol 1gm/Iv/sos

5. Tab.paromomycin 500mg/Tid

6. syp.Ambrolyte 5ml/Tid

7.Temperature/Respiratory rate /blood pressure/SpO2monitoring.

Treatment & vitals charting:

Discussion:-

Amoebic liver abscesses most commonly noticed in the age group of 20–45 years and have been noted infrequently in the extremes of ages , with an adult male to female ratio of 10:1 . Our case is of a 26-year-old male patient who presented with the complaint of fever,Cough with Expectoration that's blood tinged, SOB, weight loss for the past three months.

The diagnosis of amoebic liver abscess is sometimes difficult since its clinical manifestations are highly variable, like in our patient who presented with a long standing cough with blood tinged expectoration , intermittent high-grade fever, and progressive dyspnoea & weight loss in spite of not having symptoms like right upper quadrant abdominal pain, jaundice, , the patient still had the disease.

We report a case of Right lung lower lobe consolidation with central liquefaction secondary to an Ruptured amoebic liver abscess that was misdiagnosed as pneumonia & he was been on multiple antibiotics in outside hospitals . Pleuro-pulmonary amoebiasis is easily confused with other illnesses, and it is treated as pulmonary TB, bacterial lung abscess, and carcinoma of the lung .

Aspiration and drainage of pus from thoracic empyema usually will be helpful but in our case it's not presented as empyema Also, it has been recommended that amoebic liver abscess be treated with metronidazole or tinidazole plus a luminal amoebicide (eg. paromomycin or iodoquinol) even if the intestinal infection is not documented .

Imaging techniques such as ultrasound, computed tomography (CT), and magnetic resonance imaging (MRI) have excellent sensitivity for the detection of a liver abscess and were used with our patient, but these techniques cannot distinguish amoebic abscesses from pyogenic abscesses or necrotic tumor. The diagnosis of an amoebic liver abscess is confirmed with either serologic or antigenic testing. It can also be coupled with stool microscopy and antigen testing of the stool, with or without evaluation for the parasite in the hepatic abscess fluid.

Due the combination of findings in the imaging studies like hepatomegaly, pleural effusion with thick loculated collection, obliteration of costophrenic angles, left subdiaphragmatic collection, and involvement of the right lung which suggested an basal consolidation of the right lung, the patient was treated with a percutaneous liver abscess drainage. Following drainage, the fever improved dramatically as he continued to be under observation.

Blog Link: https://2018-21batchpgy3gmpracticals.blogspot.com/2021/08/18100006004-case-presentations.html

Page n

Competency driven assessment and testing of the student logbook author (linked below):

Please be original and refrain from plagiarism. Please share the detailed online links to every quote or reference cited in your logbook.

Please review the long and short case reports previously logged by our students and shared as samples here earlier. They are also available in the links below:

https://mbbs2k16batchgmpracticals.blogspot.com/2021/05/2k16-batch-gm-university-practical.html

https://2018-21batchpgy3gmpracticals.blogspot.com/2021/08/pg-final-year-2k18-21-batchuniversity.html?m=1

The above cases were also read out as a synchronous presentation along with answering of questions from online and offline examiners (as a part of a university summative assessment). The questions were directed to assess the presenter's competency in diagnosing and treating the above cases and is video linked there in the above two links for each of the hundreds of cases by hundreds of students.

Weekly assignment:

1) Please go through the long and short cases, one at a time in the links shared above and provide your critical appraisal of the captured data in terms of completeness, correctness and ability to provide useful leads to analyze the diagnostic and therapeutic uncertainties around the cases shared.

Please provide your peer review assessment on not only the the student's written case report but also the reading of the cases followed by the question answer session linked above in the video and share your thoughts around each answer by the student along with your qualitative insights into what was good or bad about the answer.

2: Testing scholarship competency of the examinees (ability to read comprehend, analyze, reflect upon and discuss captured patient centered data):

Please analyze the above linked long and short cases patient data by first preparing a problem list for each patient in order of perceived priority (based on the shared data) and then discuss the diagnostic and therapeutic uncertainty around solving those problems.

3) Testing competency in "Evidence based medicine":

Include the review of literature around sensitivity and specificity of the diagnostic interventions mentioned and same around efficacy of the therapeutic interventions mentioned for each patient.

4) Testing competency in patient data capture and representation through ethical case reporting/case presentation with informed consent:

Share the link to your own case report this month of a patient that you connected with and engaged while capturing his her sequential life events before and after the illness and clinical and investigational images along with your discussion of that case.

Q 5) Testing scholarship competency in logging reflective observations on your concrete experiences of this last month :

Reflective logging of one's own experiences is a vital tool toward competency development in medical education and research.

A few sample write ups on this last assignment around sharing your experience log of the month can be seen in one student's answer to Q10 in the May 2021 assignment in the link below:

https://drsaranyaroshni.blogspot.com/2021/05/assignment-patient-centred-learning.html?m=1

And another student answer to Q5 in the June and July 2021 assignment in the links below :

https://rishitha35.blogspot.com/2021/06/general-medicine-assignment.html?m=1

https://rishitha35.blogspot.com/2021/07/gm-assignment-july.html?m=1

Please reflect on and share your telemedical learning experiences from the hospital as well as community patients over the last month particularly while you were E logging their case report while even in the hospital or perhaps when locked down at home.

Clinical postings assessment

Semester	Duration of Postings	OP Cases	IP Cases

Faculty Evaluation: (One mark for each)

Semester / Date	History	Examination	Reasoning	Follow up	Additional feedback

Signature

FINAL SUMMARY

Sl no.	Description	Dates		Attendance in percentage	Status *	Signature of the teacher with date
Sl no.	Description	From	To	Attendance in percentage	Status *	Signature of the teacher with date
1	Certifiable skills
2	AETCOM Modules
3	Internal assessment Marks

References :

1) Singh, Tejinder & Aulakh, Roosy & Gupta, Priyanka & Chhatwal, Jugesh & Gupta, Piyush. (2021). Logbook for Pediatrics: Under-graduate competency-based curriculum of NMC. 10.13140/RG.2.2.18176.97287/1. Full text downloadable from : https://www.researchgate.net/publication/352350197_Logbook_for_Pediatrics_Under-graduate_competency-based_curriculum_of_NMC

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