A 48 YEAR OLD MALE CAME TO CASUALTY WITH CHIEF COMPLAINTS OF FEVER SINCE 1 MONTH, REDUSED APPETITE SINCE 1 MONTH, WEIGHT LOSS SINCE 1 MONTH, URINARY URGE INCONTINENCE SINCE 1 MONTH

  This is an online E - log book to discuss our patients de-identified health data shared after taking his/her/guardian’s signed informed consent. Here we discuss our individual patient’s problems through series of inputs from available global online community of experts with an aim to solve those patient’s clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online portfolio and your valuable inputs on the comment box.

CHIEF COMPLAINTS: 

 FEVER SINCE 1 MONTH, REDUCED APPETITE SINCE 1 MONTH, WEIGHT LOSS SINCE 1 MONTH, URINARY URGE INCONTINENCE SINCE 1 MONTH

HISTORY OF PRESENTING ILLNESS:

PATIENT WAS APPARENTLY ASYMPTOMATIC 1 MONTH BACK THEN HE DEVELOPED FEVER OF REMITTENT TYPE WITH NO AGGRAVATING FACTORS NOT ASSOCIATED WITH CHILLS  C/O GENERALIZED WEAKNESS C/O URINARY URGE INCONTINENCE WITH NO H/O POLYURIA AND PRURITIS C/O INVOLUNTARY DEFECATION DURING URINATION SINCE 15 DAYS

NO H/O CHEST PAIN, CHEST TIGHTNESS, PALPITATION, ABDOMINAL PAIN, BLEEDING MANIFESTATION

HISTORY OF PAST ILLNESSES:

K/C/O TB AND UNDERWENT TREATMENT

K/C/O DM SINCE 7 YEARS AND ON MIXTARD

K/C/O SEIZURES EPISODES 7 YEARS BACK UNDERWENT TREATMENT 

N/K/C/O ASTHMA, HTN, CAD 

PERSONAL HISTORY:

Married

Normal appetite 

irregular bowel movement (involuntary during micturition)

abnormal micturition (urge incontinence)

Adequate sleep

No addictions

FAMILY HISTORY:

N/K/C/O DM, HTN, Epilepsy, TB, asthma;

GENERAL EXAMINATION :

1. PT IS CONSCIOUS , COHERENT AND COOPERATIVE , MODERATLY BUILT AND NOURISHED .
2. NO PALLOR, ICTERUS , CYANOSIS, CLUBBING ,LYMPHADENOPATHY, EDEMA.
3. TEMP - 97.6 F
4. PR- 90 BPM
5. RR- 20 CPM
6. BP- 110/60 MM HG
7. SPO2- 98% AT RA
8. GRBS- 247MG/DL

9. SYSTEMIC EXAMINATION -

   CVS- S1,S2 HEARD,NO MURMURS

   RESPIRATORY SYSTEM-TRACHEA CENTRAL,VESICULAR SOUNDS HEARD

   ABDOMEN-NO TENDERNESS,DISTENTION,ORGANOMEGALY

   CNS-NO FOCAL DEFICITS

ON 1/05/2024 PULMONOLOGY REFERRAL WAS TAKEN I/V/O PULMONARY TB  

ON 1/05/2024 OPHTHALMOLOGY REFERRAL WAS TAKEN I/V/O DIABETIC RETINOPATHY CHANGES AND CHOROID TB

IMPRESSION NORMAL FUNDUS

NEUROSURGERY REFFERAL TAKEN ON 7/5/24 I/V/O PREVERTEBRAL ABSCESS

ADVICE: CONTINUE ATT AND REVIEW AFTER 4 WEEKS

NEPHROLOGY REFFERAL TAKEN ON 1/5/24 I/V/O ORAL CONTRAST AND IV CONTRAST ON CECT

ADVICE: TAB. N-ACETYLCYSTEINE 1200MG PO/BD

IV FLUIDS 1ML/KG/HR  FOR 12 HOURS BEFORE CECT FOLLOWED BY  IV FLUID 1ML/KG/HR AFTER CECT

PULMONOLOGY REFERRAL DONE ON 1/5/24 I/V/O PULMONARY TUBERCULOSIS

ADVICE: CST

HRCT CHEST

REVIEW WITH REPORT

OPHTHALMOLOGY REFERRAL DONE ON 1/5/24 I/V/O FUNDOSCOPY, RETINOPATHY AND CHOROID TB

IMPRESSION: NORMAL FUNDUS STUDY

UROLOGY REFERRAL DONE ON 1/5/24

ADVICE: CUE, USG KUB,CBP, URINE C/S

REVIEW WITH REPORTS

 ORTHOPEDIC REFERRAL DONE ON 3/5/24 I/V/O FEMUR IMPANT, KNEE PAINS AND PREVERTEBRAL COLLECTION FROM C4 TO L1 LEVEL 85 X 30 X 36 AND EROSION OF C6 VERTEBRAL BODY.

ENT REFERRAL TAKEN ON 4/5/24 I/V/O VOCAL POLYPS AND ? NASAL POLYP

ADVICE: CONTROL ACTIVE STAGE OF TB AND REVIEW TO ENT OPD FOR ENDOSCOPY

CONTINUE MEDICATIONS ADVISED BY PRIMARY PHYSICIAN

PROVISIONAL DIAGNOSIS:

PYREXIA UNDER EVALUATION SECONDARY TO COMMUNITY ACQUIRED PNEUMONIA

DISSEMINATED TB PULMONARY TB POTTS SPINE RENAL TB

CHRONIC KIDNEY DISEASE STAGE 3 B

CHRONIC PANCREATITIS

ANEMIA OF CHRONIC DISEASE

Investigations:

Name  Value  Range	Name  Value  Range
COMPLETE URINE EXAMINATION (CUE)   29-04-2024 07:09:PM  COLOUR Pale yellow    APPEARANCE Clear    REACTION Acidic    SP.GRAVITY 1.010    ALBUMIN +++    SUGAR Nil    BILE SALTS Nil    BILE PIGMENTS Nil    PUS CELLS 4-5    EPITHELIAL CELLS 3-4    RED BLOOD CELLS Nil    CRYSTALS Nil    CASTS Nil    AMORPHOUS DEPOSITS Absent    OTHERS Nil	LIVER FUNCTION TEST (LFT)   29-04-2024 07:09:PM  Total Bilurubin 0.57 mg/dl 1-0 mg/dl  Direct Bilurubin 0.20 mg/dl 0.2-0.0 mg/dl  SGOT(AST) 15 IU/L 35-0 IU/L  SGPT(ALT) 10 IU/L 45-0 IU/L  ALKALINE PHOSPHATASE 288 IU/L 128-53 IU/L  TOTAL PROTEINS 5.8 gm/dl 8.3-6.4 gm/dl  ALBUMIN 2.66 gm/dl 5.2-3.5 gm/dl  A/G RATIO 0.85
BLOOD UREA   29-04-2024 07:09:PM 58 mg/dl 42-12 mg/dl	SERUM CREATININE   29-04-2024 07:09:PM 2.6 mg/dl 1.3-0.9 mg/dl
SERUM ELECTROLYTES (Na, K, C l)   29-04-2024 07:09:PM  SODIUM 136 mmol/L 145-136 mmol/L  POTASSIUM 3.6 mmol/L 5.1-3.5 mmol/L  CHLORIDE 104 mmol/L 98-107 mmol/L	HBsAg-RAPID   29-04-2024 07:11:PM Negative
Anti HCV Antibodies - RAPID   29-04-2024 07:11:PM Non Reactive	BLOOD UREA   30-04-2024 11:35:PM 60 mg/dl 42-12 mg/dl
SERUM CREATININE   30-04-2024 11:35:PM 2.5 mg/dl 1.3-0.9 mg/dl	SERUM ELECTROLYTES (Na, K, C l)   30-04-2024 11:35:PM  SODIUM 135 mmol/L 145-136 mmol/L  POTASSIUM 4.0 mmol/L 5.1-3.5 mmol/L  CHLORIDE 101 mmol/L 98-107 mmol/L
POST LUNCH BLOOD SUGAR   01-05-2024 12:02:PM 168 mg/dl 140-0 mg/dl	BLOOD UREA   01-05-2024 10:53:PM 62 mg/dl 42-12 mg/dl
SERUM CREATININE   01-05-2024 10:53:PM 2.5 mg/dl 1.3-0.9 mg/dl	SERUM ELECTROLYTES (Na, K, C l)   01-05-2024 10:53:PM  SODIUM 135 mmol/L 145-136 mmol/L  POTASSIUM 4.2 mmol/L 5.1-3.5 mmol/L  CHLORIDE 104 mmol/L 98-107 mmol/L
BLOOD UREA   02-05-2024 11:51:PM 64 mg/dl 42-12 mg/dl	SERUM CREATININE   02-05-2024 11:51:PM 2.5 mg/dl 1.3-0.9 mg/dl
SERUM ELECTROLYTES (Na, K, C l)   02-05-2024 11:51:PM  SODIUM 134 mmol/L 145-136 mmol/L  POTASSIUM 4.0 mmol/L 5.1-3.5 mmol/L  CHLORIDE 101 mmol/L 98-107 mmol/L

Chest X-ray: 

X-rays:

MRI- 

CT- 

HRCT DONE ON 2/05/2024

IMPRESSION CHRONIC COLLAPSE OF LEFT UPPER LOBE WITH CAVITIES AND BRONCHIECTASIS WITHIN

PATCHY CONSOLIDATION AND MULTIPLE SMALL NODULES IN B/L LUNGS

MULTIPLE VARIABLE SIZED THIN WALLED CAVITIES IN B/L UPPER LOBES AND RIGHT MIDDLE LOBE

RIGHT KIDNEY SHOWS A 54X34 MM SPACE OCCUPYING LESION

PREVERTEBRAL COLLECTION FROM C4-D1 LEVEL 85X30X36 MM

EROSIONS OF C6 VERTEBRAL BODY

ECG-NORMAL SINUS RHYTHM

USG ABDOMEN WAS DONE ON 29/4/24

IMPRESSION: CHRONIC PANCREATITIS

LEFT KIDNEY SHOWS GRADE II RPD CHANGES WITH SIMPLE RENAL CYST

RIGHT KIDNEY SHOWS GRADE I RPD CHANGES

TREATMENT:

ATT STARTED ON 5/5/24

30/4/24:

IV FLUIDS- NS AT 75ML/HOUR

INJ. AUGMENTIN 1.2GM IV/BD  8AM---X--8PM

INK PAN 40MG IV/OD 7AM--X--X

INJ. NEOMOL IGM IV/SOS

TAB. AZITHROMYCIN 500MG PO/OD AT 2PM

INJ. OPTINEURON 1 AMP IN 100ML NS

TAB. DOLO 650MG TID  8AM--2PM--8PM

INJ. HAI S/C TID ACCORDING TO GRBS

NEBULISATION WITH BUDECORT 12TH HOURLY

                                          IPRAVENT 6TH HOURLY 

1/5/24:

IV FLUIDS NS AT 75ML/HOUR

INJ. AUGMENTIN 1.2GM IV/BD  8AM---X--8PM

INK PAN 40MG IV/OD 7AM--X--X

INJ. NEOMOL IGM IV/SOS

TAB. AZITHROMYCIN 500MG PO/OD AT 2PM

INJ. OPTINEURON 1 AMP IN 100ML NS

TAB. DOLO 650MG TID  8AM--2PM--8PM

INJ. HAI S/C TID ACCORDING TO GRBS

NEBULISATION WITH BUDECORT 12TH HOURLY

                                          IPRAVENT 6TH HOURLY

2/5/24:

IV FLUIDS NS AT 75ML/HOUR

INJ. AUGMENTIN 1.2GM IV/BD  8AM---X--8PM

INK PAN 40MG IV/OD 7AM--X--X

INJ. NEOMOL IGM IV/SOS

TAB. AZITHROMYCIN 500MG PO/OD AT 2PM

INJ. OPTINEURON 1 AMP IN 100ML NS

TAB. DOLO 650MG TID  8AM--2PM--8PM

INJ. HAI S/C TID ACCORDING TO GRBS

NEBULISATION WITH BUDECORT 12TH HOURLY

                                          IPRAVENT 6TH HOURLY

3/5/24:

IV FLUIDS NS AT 75ML/HOUR

INJ. PIPTAZ 4.5 GM IV/STAT FOLLOWED BY INJ. PIPTAZ 2.25G IV/TID

INJ. AUGMENTIN 1.2GM IV/BD  8AM---X--8PM

INK PAN 40MG IV/OD 7AM--X--X

INJ. NEOMOL IGM IV/SOS

TAB. AZITHROMYCIN 500MG PO/OD AT 2PM

INJ. OPTINEURON 1 AMP IN 100ML NS

TAB. DOLO 650MG TID  8AM--2PM--8PM

INJ. HAI S/C TID ACCORDING TO GRBS

NEBULISATION WITH BUDECORT 12TH HOURLY

                                          IPRAVENT 6TH HOURLY

4/5/24:

IV FLUIDS NS AT 75ML/HOUR

INJ. PIPTAZ 4.5 GM IV/STAT FOLLOWED BY INJ. PIPTAZ 2.25GM IV/TID

INJ. AUGMENTIN 1.2GM IV/BD  8AM---X--8PM

INJ. PAN 40MG IV/OD 7AM--X--X

INJ. NEOMOL IGM IV/SOS

TAB. AZITHROMYCIN 500MG PO/OD AT 2PM

INJ. OPTINEURON 1 AMP IN 100ML NS

TAB. DOLO 650MG TID  8AM--2PM--8PM

INJ. HAI S/C TID ACCORDING TO GRBS

NEBULISATION WITH BUDECORT 12TH HOURLY

                                          IPRAVENT 6TH HOURLY

5/5/24:

IV FLUIDS NS AT 75ML/HOUR

INJ. PIPTAZ 2.25GM IV/TID

INJ. PAN 40MG IV/OD

INJ. OPTINEURON 1 AMP IN 100ML NS

INJ. HAI S/C TID ACCORDING TO GRBS

INJ. TRANEXA 100MG IV/SOS

TAB. RIFAMPICIN 400MG PO/OD 

TAB. ISONIAZID 225MG PO/OD 

TAB. PYRAZINAMIDE 1125MG PO/OD

TAB. ETHAMBUTOL 675MG PO/OD 

TAB. BENADON 40MG PO/OD 

6/5/24:

IV FLUIDS NS AT 75ML/HOUR

INJ. PIPTAZ 2.25GM IV/TID

INJ. PAN 40MG IV/OD

INJ. OPTINEURON 1 AMP IN 100ML NS

INJ. HAI S/C TID ACCORDING TO GRBS

INJ. TRANEXA 100MG IV/SOS

TAB. RIFAMPICIN 400MG PO/OD 

TAB. ISONIAZID 225MG PO/OD 

TAB. PYRAZINAMIDE 1125MG PO/OD

TAB. ETHAMBUTOL 675MG PO/OD 

TAB. BENADON 40MG PO/OD

7/5/24:

IV FLUIDS NS AT 75ML/HOUR

INJ. PIPTAZ 2.25GM IV/TID

INJ. PAN 40MG IV/OD

INJ. OPTINEURON 1 AMP IN 100ML NS

INJ. HAI S/C TID ACCORDING TO GRBS

INJ. TRANEXA 100MG IV/SOS

TAB. RIFAMPICIN 400MG PO/OD 

TAB. ISONIAZID 225MG PO/OD 

TAB. PYRAZINAMIDE 1125MG PO/OD

TAB. ETHAMBUTOL 675MG PO/OD 

TAB. BENADON 40MG PO/OD

 

 

 

 

OSCE and learning points

 OSCE questions and answers: 

1. What is steroid induced Diabetes Mellitus? 

Steroid-induced diabetes mellitus is defined as an abnormal increase in blood glucose associated with the use of glucocorticoids in a patient with or without a prior history of diabetes mellitus. The criteria for diagnosing diabetes by the American Diabetes Association is an 8 h fasting blood glucose ≥ 7.0 mmol/L (126 mg/dL), 2 h post 75 g oral glucose tolerance test (OGTT) ≥ 11.1 mmol/L (200 mg/dL), HbA1c ≥ 6.5% or in patients with symptoms of hyperglycemic, a random plasma glucose of ≥ 11.1 mmol/L (200 mg/dL).

2. Cushing Syndrome and Diabetes II-

Cushing's syndrome is commonly complicated with an impairment of glucose metabolism, which is often clinically manifested as diabetes mellitus. The development of diabetes mellitus in Cushing's syndrome is both a direct and indirect consequence of glucocorticoid excess. Indeed, glucocorticoid excess induces a stimulation of gluconeogenesis in the liver as well as an inhibition of insulin sensitivity both in the liver and in the skeletal muscles, which represent the most important sites responsible for glucose metabolism. In particular, glucocorticoid excess stimulates the expression of several key enzymes involved in the process of gluconeogenesis, with a consequent increase of glucose production, and induces an impairment of insulin sensitivity either directly by interfering with the insulin receptor signaling pathway or indirectly, through the stimulation of lipolysis and proteolysis and the consequent increase of fatty acids and amino acids, which contribute to the development of insulin resistance. Moreover, the peculiar distribution of adipose tissue throughout the body, with the predominance of visceral adipose tissue, significantly contributes to the worsening of insulin resistance and the development of a metabolic syndrome, which participates in the occurrence and maintenance of the impairment of glucose tolerance. Finally, glucocorticoid excess is able to impair insulin secretion as well as act at the level of the pancreatic beta cells, where it inhibits different steps of the insulin secretion process. This phenomenon is probably responsible for the passage from an impairment of glucose tolerance to an overt diabetes mellitus in susceptible patients with Cushing's syndrome.

Learning points: 

- I learnt how to clinically differentiate between Diabetes I and II, MODY and juvenile type of diabetes 

-  difference between osteoarthritis and rheumatoid arthritis 

- complications of dengue

- learnt about ventilation perfusion ratio and how it gets affected in different lung conditions. 

- importance of holisitic approach and understanding

- 

- 

A 77F came to the ophthalmology opd with chief complain of diminished vision

 This is an online E - log book to discuss our patients de-identified health data shared after taking his/her/guardian’s signed informed consent. Here we discuss our individual patient’s problems through series of inputs from available global online community of experts with an aim to solve those patient’s clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online portfolio and your valuable inputs on the comment box.

 A 77 year old female, a housewife by occupation came to the ophthalmology opd with chief complaints of diminision of vision in the right eye since 6 months. She was referred from Ophthalmology due to uncontrolled blood sugar levels while evaluating her for cataract surgery. 

History of presenting illness: 

Patient was apparently asymptomatic 1 year back when she had nocturia due to which she went to the hospital and was diagnosed with diabetes for which she was medication. She takes Glimeperide 1mg and Metformin 500mg daily ever since. 

Patient has itchy skin lesion over left foot since one year. She also complains of itching over genitals since one year. 

She developed diminished vision 6 months back which is insidious in onset, gradual in progression. h/o lacrimation and itching. Not associated with redness. 

Past history : 

Known case of hypertension since 1 year and on medication 

Not a known case of TB, asthma, epilepsy

Personal history : 

Mixed diet

Appetite is reduced 

Normal bowel and bladder movements 

Sleep is adequate 

No Addictions 

Daily routine : 

Before 

She used to wake up at 5:00 am. She walks 1/2 a kilometer to buy milk. Then at 8:00 am after having breakfast, she goes and sits at a shop beside the house and returns home at 2:00 pm for lunch and then goes to sleep. After waking up, she has dinner and sleeps at 10:00 pm. 

Now 

She used to wake up at 5:00 am. She walks 1/2 a kilometer to buy milk. Then at 8:00 am after having breakfast, takes medication. She goes and sits at the shop and returns home at 2:00 pm for lunch and then goes to sleep. After waking up, she will have dinner and sleep at 10:00 pm. 

There is no change in the routine of the patient except for medication for diabetes and hypertension being taken regularly. 

Family history: 

Not significant 

General examination 

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

Patient was moderately built and nourished 

Vitals

BP 140/90 mm of Hg

Pulse 80beats /min

Temperature afebrile

Respiratory rate  16 cycles/min

No pallor, icterus, cyanosis, clubbing, lymphadenopathy 

Eye: 

Right eye 

Diminised vision 

Ocular movements are not limited 

                              Right eye                         Left eye

Visual acuity         Counting fingers, 2m       6/60

Lids                       normal                             normal

Conjunctiva           Muddy                             Muddy

Cornea                  nasal pterygium              nasal pterygium

Anterior chamber  PACD = 1/2 CT               PACD = 1/2 CT

Iris                        

Pupil                   normal size, reactive     normal size, reactive

Lens                   IMSC grade I - II                

Skin Examination: 

single well defined

Silvery white plaque noted over the left foot 

Systemic examination:

CVS- S1 S2 heard no murmurs

CNS- No focal neurological deficit

RS- Normal vesicular sounds heard

P/A- 

scaphoid abdomen 

non tender, no palpable mass

bowel sounds heard 

Provisional Diagnosis:  Metabolic Syndrome 

Investigations: 

Treatment History: 

1. tab. LOSARTAN 40 mg 
   
2. Injection Human Actrapid 10 IU given before each meal 
3. Inj. NPH 8 IU twice daily 

Internal Assessment June 2023