GENERAL MEDICINE BLENDED ASSESSMENT AUGUST 2021


AUGUST 25,2021
QUESTION NO:1
Testing peer Review competency 
LINK:

REVIEW:
Long case: This long case is of Acute Glomerulopathy .The  history was well presented and explained in detail .The signs and symptoms are mentioned well enough to come through a diagnosis.The presentation was good with pictures and clear explanation of symptoms.
There are two short cases one is regarding Idiopathic Parkinsons Disease and the other one is Iatrogenic Cushings Syndrome. Both cases are explained in a good way with a clear explanation of symptamology, and did all the necessary investigations to conclude a particular diagnosis. Photographs are showed and treatment plan was given in detail.

QUESTION NO:2

Testing scholarship competency of the examinees; ability to read comprehend, analyze, reflect upon and discuss captured patient centered data. Analyze the above linked long and short cases patient data by first preparing a problem list for each patient in order of perceived priority and then discuss the diagnostic and therapeutic uncertainty around solving those problems.
 
Long case :Acute Glomerulopathy
Problem list:
  • The patient presented with facial puffiness with pedal edema and next morning also noticed that he developed bilaterally symmetric ,pitting type pedal edema extending upto middle of his legs.
  • He had severe joint pains which were assymetric and gradually became bilaterally symmetrical and involving small joints of his hands and wrist.
  • the joint pains were associated with significant local edema and painful limitation of movements
  • debiliating early morning pains and limitation of movements in his hands, wrists and feet which usually lasts about an hour.he reported that the pains and limitations of movements improved with activity,with gradual reduction in edema in joints.

  • Recently, 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

  • 3 day history of anasarca, frothy urine and gradually decreasing urine output.
Anasarca and frothy urine with decreasing urine output suggest a renal pathology. Proteinuria causing anasarca likely due to glomerular pathology. Pointing  acute development of glomerulonephritis secondary to poorly treated bilaterally symmetrical polyarthritis

Short case-1:
  • The patient presented with a 2 month history of progressive asymmetric involuntary movements of his right index and middle fingers.
  • The patient reports that he first noticed them happening nearly 6 months ago, which was very small in amplitude, affecting these two fingers only.
  • His  handwriting has become ugly with very small letters. On interviewing further, the patient reports that he feels stiffness in his wrists (Right>Left), which has now ascended to his elbows.
  • Involuntary movements - Resting tremors of Right upper limb , 3-4Hz, high amplitude.
    Gait - Reduced arm swing
  • Cog wheel rigidity at wrist joint
  • Clarity in speech is decreased
The diagnosis stated as Idiopathic Parkinson's Disease Stage 1 with denovo HTN , Multiple System Atrophy - Parkinsonian Type (MSA-P).

short case-2:

  • 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 .


QUESTION NO: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.

Review : The longcase is case of Acute glomerulonephritis secondary to poorly treated Bisymmetrical Polyarthritis and the pathophysiology is well explained symptomatically.

Signs and Symptoms of acute glomeruonephritis:
  • breathlessness, palpitations or chest pain.
  • Severe joint pains, which were initially asymmetric and gradually became bilaterally symmetrical and involving the small joints of his hands and wrist. 
  •  limitation of movements in his hands, wrists and feet
  • Changes to your diet so that you eat less protein, salt and potassium.Corticosteroids such as prednisone.
  • Dialysis, which helps clean the blood, remove extra fluid and control blood pressure.
  • Diuretics (water pills) to reduce swelling
Rheumatoid Arthritis (RA) is a widespread disease and its renal involvement, relatively common, is clinically significant because worsens course and mortality of the primary disease. In order of frequency: glomerulonephritis and amyloidosis (60-65% and 20-30% respectively), followed by acute or chronic interstitial nephritis.

SHORT CASES:

PARKINSONS DISEASE:

Parkinson's disease signs and symptoms can be different for everyone. Early signs may be mild and go unnoticed. Symptoms often begin on one side of your body and usually remain worse on that side, even after symptoms begin to affect both sides.

  • tremors
  • Slowed movement (bradykinesia)
  • Rigid muscles
  • Impaired posture and balance.
  • Loss of automatic movements
  • Speech changes
  • Writing changes. 
The differential diagnosis of parkinsonian syndromes continues to challenge clinicians. The clinical diagnosis of idiopathic Parkinson's disease is correct in only about three quarters of cases when reevaluated neuropathologically, emphasizing the need for more discriminative diagnostic criteria. 
The clinical spectrum of brain stem Lewy body idiopathic Parkinson's disease itself may be heterogeneous, including dementing and nondementing, familial and sporadic, and levodopa-responsive and -nonresponsive subgroups.
 Recent clinicopathologic evidence suggests that other parkinsonian syndromes such as progressive supranuclear palsy may also be neuropathologically heterogeneous.
 Pharmacologic criteria of dopaminergic responsiveness have no absolute power of differentiating between idiopathic Parkinson's disease and other parkinsonian disorders, although an absent response argues against idiopathic Parkinson's disease. 
The best diagnostic imaging criteria still come from positron emission tomography studies of the functional integrity of the nigrostriatal dopaminergic system, but more widely applicable techniques are needed. 
Promising perspectives for this have come form studies of D2-receptor binding with iodobenzamide single photon emission computed tomography in parkinsonian syndromes


CUSHINGS SYNDROME:
Cushing’s disease, or pituitary ACTH dependent Cushing’s syndrome, is a rare disease responsible for increased morbidity and mortality

Chronic glucocorticoid excess, or Cushing’s syndrome, may be due to ACTH-dependent (80% cases) or –independent (20% cases) causes (Table ​(Table1).. The latter are mainly due to benign (60%) or malignant (40%) adrenal tumors. ACTH overproduction may be of pituitary origin (85% cases) or result from ectopic tumor secretion (15% cases). The term Cushing’s disease is specifically applied to ACTH-secreting pituitary tumors. Cushing’s disease, first described by Harvey Cushing in 1932, represents the most frequent cause of Cushing’s syndrome .


Chronic glucocorticoid excess, or Cushing’s syndrome, may be due to ACTH-dependent (80% cases) or –independent).. The latter are mainly due to benign (60%) or malignant (40%) adrenal tumors. ACTH overproduction may be of pituitary origin (85% cases) or result from ectopic tumor secretion (15% cases). The term Cushing’s disease is specifically applied to ACTH-secreting pituitary tumors. Cushing’s disease, first described by Harvey Cushing in 1932, represents the most frequent cause of Cushing’s syndrome.

Clinical characteristics

  • Hypercortisolic state may include several clinical signs .
  • Obesity: obesity with centripetal fat deposition (face, supraclavicular and dorso-cervical fat pads), facial plethora, rounded face, buffalo-hump
  • Signs of protein wasting: thin skin, abdominal purple to red and wide cutaneous striae (abdomen, flanks, breasts, hips, axillae), easy bruising, slow healing, muscle wasting (lower limbs muscle atrophy)
  • Bone wasting leading to osteoporosis (possibly leading to fractures)
  • High blood pressure
  • Impaired immune defense mechanisms with increased rate of infections
  • Gonadal dysfunction and hyperandrogenism: hirsutism (more frequently on the face), menstrual irregularity (oligoamenorrhea, amenorrhea)
  • Mild to severe psychic disturbances(anxiety, depression, irritability…)


QUESTION:4

 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.


I did not get chance to make my own log this month

Question 5:

Testing scholarship competency in logging reflective observations on your concrete experiences of this last month
In this month we came through some cases and learnt a lot .It helped to gain some knowledge. We are very thankful to general medicine department for providing many cases of different patients through these elogs.

Thank you 
K.Sri Harshitha
Roll No. 58
3rd Sem.




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