General medicine Bimonthly assessment June 2021 by Roll 106 Ananya Pulikandala 2019 batch
Bimonthly assessment(General medicine department)
Question 1: Reviewing blogs written by our seniors(8thsemester)
1.https://dandushivani.blogspot.com/2021/06/covid-e-logs.html?m=1
- The ongoing covid pandemic has undergone many changes both externally (the symptomatology in patients who have contracted COVID) and the virus itself isn't the same as it was an year ago.
- The blog clarifies every doubt of the person who reads it, even a non medical professional could understand it very well, although it could have featured more number of images to visualize the case scenario.
- The patient's history and laboratory investigations have been sorted very well.
- The pulmonology case history was very specific(the symptoms and chronological order) and precise giving an idea of the pathology that the patient has encountered.
- A detailed explanation of the symptoms could've been more appreciated.
- The pharmacological interventions have been very clearly explained for each systemic case(the mechanism of action have been briefly described).
- The explanations were kept short and direct.
- All the questions were cleared but the answers were abstract.
- Although the pharmacological interventions in the case were well explained, the images would've made the work more easier.
- Also as it helps in pictorial memory, it could've been more fascinating.
- The cases were very well explained with all the physiological,pathological and pharmacological findings.
- In order to explain the dis-ease processes, A comparative approach was made which was quite easy to understand.
- The explanation for each case was very complex and vague.
- Although it's a suggestion that each case was well researched.
8.https://preethicheera.blogspot.com/2021/05/general-medicine-case-presentation-may.html?m=1
- The complications associated with the disease processes have been clearly mentioned.
- The etiology of each case was also well explained along with the treatment of choice.
- The elog of the case was showcasing all the lab reports which clearly were indicative of the respective diagnosis.
- Although If the use of ellaborate videos and images for the general examination and Systemic examination could've been more appreciated.
- The resons for the complications in the patient were accurate.
- Also finding out the loopholes in the investigations too, gives us a promising idea as to how our future doctors are gonna be.
Chief complaints : A 52 year old male patient, presented to the OPD
- With slurring of speech and deviation of mouth to one side
History :(given by the patient himself)
- Giddiness 7 days back. It started at around 7 am when the patient was doing his usual morning routine. He suddenly felt giddy and took rest, after which it subsided briefly. This was associated with 1 episode of vomiting on the same day.
- Patient was asymptomatic for 3 days, after which he consumed a small amount of alcohol.
- He then developed giddiness, that was sudden in onset, continuous and gradually progressive. It increased in severity upon getting up from the bed and while walking.
- This was associated with Bilateral Hearing loss, aural fullness and presence of tinnitus.
- He has associated vomiting- 2-3 episodes per day, non projectile, non bilious containing food particles.
- Patient has H/o postural instability- he is unable to walk without presence of supports, swaying is present and he has tendency to fall while walking
- No diplopia, dysphagia, dysarthria
- No H/o any seizure like activity.
Medical History-
The patient was diagnosed with HTN of sudden onset for which he wasn't taking any medications.
Surgical History- Not significant .
Family history - not significant.
Personal history -
Diet- Mixed
Appetite- Normal
Sleep- Adequate
Bowel and Bladder movement- regular
Addictions- Chronic smoker, smokes 1 pack of beedi per day
Chronic alcoholic, since 30 years, consumes 90-180 ml daily.
GENERAL EXAMINATION:
The patient is moderately built and well nourished.
Pallor- Absent
Icterus- Absent
Clubbing- Absent
Cyanosis- Absent
Lymphedenopathy- Absent
Edema- Absent
The patient was conscious, coherant, and co-operative and well oriented to time, place and person.
VITALS-
Temperature- Afebrile
BP- 130/100mmHg
Pulse- 100beats/min
Respiratory Rate- 20cycles/min
Oxygen saturation- 97% at room temperature.
SYSTEMIC EXAMINATION:
RESPIRATORY SYSTEM-
Normal vesicular breath sounds heard.
No wheezing heard.
No crackles heard.
Centrally placed trachea.
CVS-
S1 and S2 heard.
Cardiac murmurs absent.
PER ABDOMEN-
Soft and tender.
No organomegaly
CNS-
- No sensory symptoms are present
- Motor system examination:
RIGHT LEFT
TONE
Upper limb Normal Normal
Lower limb Normal Normal
POWER
Upper limb 5/5 5/5
Lower limb 5/5 5/5
REFLEXES +2 +2
GAIT- Wide based- Ataxic gait
CRANIAL NERVES-
- Tests for VIII nerve (vestibulocochlear):
Rinnes test- Right ear: BC>AC, Left ear: AC>BC Webers test: No lateralisation.
NYSTAGMUS-
Bilateral horizontal nystagmus, vertical upbeat nystagmus, more on right lateral position with a fast component to the left.
INVESTIGATIONS:
COMPLETE URINE EXAM:
Colour- Pale yellow
Appearance- cloudy
Reaction- Acidic
Sp. Gravity- 1.010
Albumin- +
Sugar- nil
Bile salts- Nil
Bile pigments- Nil
Pus cells- 3-4
Epithelial cells- 2-3
Red blood cells- Nil
Crystals- Nil
Casts- Nil
Amorphous deposits- Absent
Others- Nil
RFT:
Urea- 28 mg/dl
Creatinine- 0.9 mg/dl
Uric acid- 7.4 mg/dl
Calcium- 9.8 mg/dl
Phosphorous- 1.3 mg/dl
Sodium- 140 mEq/L
Potassium- 3.5 mEq/L
LIVER FUNCTION TESTS:
Total Bilirubin- 2.00 mg/dl
Direct bilirubin- 0.55 mg/dl
SGOT (AST)- 17 IU/L
SGPT (ALT)- 18 IU/L
Alkaline phosphatase- 187 IU/L
Total proteins- 7.2 g/dl
Albumin- 4.5 g/dl
A/G Ratio- 1.72
CT SCAN- Computed tomography scan of the brain was done, which revealed a cerebellar infarct. 
Clinical diagnosis :
Cerebellar ataxia secondary to acute CVA (cerebrovascular accident)due to infarction of right inferior cerebellar hemisphere.
Anatomy of the cerebellum
- Outer gray matter called cerebral cortex, extensivly folded forming folia
- Inner white matter, showing distinctive treelike pattern called Arbor vitae (tree of life)
- 4 pairs of nuclei within white matter,the deep cerebral nuclei.
- Cerebral cortex:
Functions of the cerebellum :
- Maintenance of Equilibrium, balance, posture, eye movement
- Coordination of half-automatic movement of walking and posture maintenance
- Responsible for gait of the individual .
- Adjustment of Muscle Tone
- Motor Learning - Motor skills.
- Cognitive function= Procedural learning, executive functions, language processing, visual spatial orientation, sensory processing, timing, attention
- Executive function impairment: Defecit of attention, sequencing and timing
Case related questions:
1.Did the patient's history of HTN be related to his current situation?
- Hypertension induces adaptive changes in systemic and cerebral arteries known as hypertrophic and eutrophic remodeling. In hypertrophic remodeling smooth muscle cells undergo hypertrophy or hyperplasia, and grow inward encroaching into the lumen of the artery. This process increases the wall thickness and reduces the lumen of the vessel, Therefore making the blood supply to the region progressively low.
- Hypertrophy and remodeling are adaptive responses aimed at reducing stress on the vessel wall and protecting downstream microvessels from the effect of increased pressure.
Reference article for the above question:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2475602/
2.Does the patient's history of alcoholism make him more susceptible for haemorrhagic stroke?
- There was a consensus among reports that heavy alcohol consumption was associated with a higher risk of hemorrhagic strokes. Controversy remains regarding the effect of mild-to-moderate alcohol consumption: while some studies reported a protective effect, others found a dose-dependent linear relationship between the amount of alcohol consumed and the risk of hemorrhagic stroke.
- The differential effect of moderate alcohol consumption on hemorrhagic compared to ischemic strokes is mostly attributed to alcohol- and withdrawal-induced sudden elevations of blood pressure, and coagulation disorders.
- https://pubmed.ncbi.nlm.nih.gov/15330400/ "Reference article"
here's the link to access the history ans lab investigations of a patient with hypertensive nephropathy.
https://61tejarshini.blogspot.com/2021/06/general-medicine-case-discussion.html?m=1
HTN is a multifactorial disease. The interplay between genetic predisposition, aging, and other cardiovascular risk factors makes it difficult to determine one single etiology. If left untreated, HTN could lead to left ventricular hypertrophy (LVH), hypertensive nephropathy, and most importantly a significant increase in the risk of stroke.
The hypertensive nephropathy is kidney disease. The blood pressure (high blood pressure) damages the vasculature in the kidneys.
- Hypertensive nephropathy development:- Renal failure is seldom caused by this condition. Due to renal damage, it can be considered that patients are less resistant to the renal and thus less equipped for surgery stress or acute disease. Steps to shield the kidneys from any preventable damage must be taken before the illness and before the operation.
It's not news to y'll as to how this pandemic has adversely effected the whole system of education and careers. Even though our government has taken some innovative steps to evoke the spirit of studying from our homes, we ,as students,sometimes, tend to fail in doing so.
Therefore the responsibility of making studies even more interesting lies on the institution and i believe that my college has excelled in having us forgotten about the communication gap that we've been facing due to the lock down.
We havent been deprived of the clinical exposure (which the new curriculum emphasises on). Through the elogs and active communication with our department HODs and collective guidance by our interns and pgs we have been able to contact patients directly and obtain all the necessary information for the diagnosis; and ofcourse understanding the disease mechanisms too. All thanks to our enthusiastic seniors and professors !!
And Not to forget mentioning our current year study professors, the efforts they put, in clarifying our doubts and giving us an overview of the subject is worthwhile.
The active group discussions we have during the class hours,the projects they assign; they don't seem like a burden to us at all.. Instead we look forward to having more recreational activities like that.
Although we still miss attending our physical classes and postings.Hoping to get back to college soon!
Thank-you
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