CASE
– 1
Experience:
-
18 year old
girl presented with multiple joint pain, joint stiffness, joint swelling and fever since 1 year.
Patient's HIPAA de-identified online-health-record with raw data and clinical images here
Reflection-
Ø Patient had morning time
joint stiffness.
Ø It involved symmetrical
joints.
Ø Joint had slight increased
temperature .
Ø Mild oedema in all over
body with swollen face.
Ø Some whitish macular
lesion on upper back.
Conceptualization-
Ø 0n the basis of presenting
symptoms signs and examination, we had reached the diagnosis of RHEUMATOID
ARTHRITIS.
Ø Oedema was due to use of
steroid, taken by patient, prescribed by local physician.
Ø Some whitish lesion seems
as MELESSEZIA FURFUR due to decrease immunity due to steroid uptake.
Action-
Ø Complete haemogram for
cell count, which was normal.
Ø RFT- was normal
Ø CXR- to rule out CAPLAN
SYNDROME ( no parenchymal involvement)
Ø RA factor- to rule out
severity of disease, (positive indicate severe course) was –ve.
Ø TREATMENT- Methotrexate- 15 mg once in week
prednisolone- 10 mg
folic acid- 5mg once in week.
Learning point-
Ø Patient had
no such typical joint deformity as described for RA, neither she had RA
positive though patient had diagnosed as RA. So for diagnosis of RA, its not
always necessary that patient present with typical deformity or RA factor
positive.
Ø PATIENT WAS
ON 7.5 MG METHOTREXATE FOR ABOUT WITHOUT
MUCH BENEFIT. BUT ON INCREASING DOSE UPTO
15MG PATIENT START RESPONDING ON CONSIDERABLE LEVEL.
Patient's HIPAA de-identified online-health-record with raw data and clinical images here
CASE-2
Experience-
26 year old
male with sudden closure of left eye , diplopia with imbalance during walking.
Patient's HIPAA de-identified online-health-record with raw data and clinical images here
Reflection-
Ø On examination patient had
slight exotropia on left eye with mild dilated pupil with comparison to right
eye with ptosis. It indicates complete third nerve palsy.
Ø Patient use to loss
balance on standing only when eyes are closed, it indicates some cerebeller
involvement.
Conceptualization-
Ø
As paient had no signs of raised ICT like congestion,
vomiting its least likely due to cerebral haemorrhage.
Ø
Patient was fully conscious well oriented, it might be his
lucid interval but there was no history of trauma and previous loss of
consciousness. So patient was not on lucid interval.
Action-
Ø Patient had sent to urgent
CT scan head to rule out any haemorrhage. But no evidence of any haemorrhage.
Ø MRI brain with
angiography- 2 tiny foci, one on left peri aqueductal midbrain and another on
left posterior perital lobe.
Ø Lipid profile to rule out
atherosclerosis was normal.
Ø EEG- to record brain
activity was almost normal.
Ø Treatment-
Clopidogril, to
normalize platelet function.
Atoravastatin, to
lower LDL level.
Steroid, if any
inflammation in nerves or in part of brain.
Learning point-
Ø On CT, no
finding of haemorrhage, so we got time for further planning of m/m as it ruled out any emergency situation.
Ø Patient was
improving with steroid, suggestive of some autoimmunity like MULTIPLE SCLEROSIS.
Patient's HIPAA de-identified online-health-record with raw data and clinical images here
CASE- 3
Experience -
58 year old male, complaining of heat intolerance
since 20 year.
He was apparently alright 20 year back. Then he
noticed excess heat production on his body during exertion, which was
continuously increasing and finally reached at state where he is unable to
tolerate it.
Patient's HIPAA de-identified online-health-record with raw data and clinical images here
Reflection-
During exertion or in summer season,when body
produce heat, patient unable to loss heat by his skin through sweating. It
increases body temperature sufficient to cause intolerance.
Conceptualization-
patient had patchy area of coarseness mainly on his
dorsum of hand and back,which was showing absent sweating. These areas are
increasing with time continuously, that’s why patients problem of intolerance
is increasing continuously.
Action-
Ø Complete haemogram- to rule out any chronic infections.
Ø RFT LFT- to assess normal functioning.
Ø SKIN BIOPSY- To know the anatomical distribution of sweat
glands,both eccrine and apocrine gland was absent and hyperkeratosis and
parakeratosis too in affected are
Ø TEST EXERSICES- to know about functioning of sweat gland.
Ø LIGHT REFLEXES- edies pupile are absent, it ruled out ROSS
SYNDROME.
LEARNING POINT-
Ø Patients had
normal light reflex and almost normal joint reflexes, which is against the diagnosis
of ross syndrome.
Ø Patient had
no other ectodermal anomaly except sweat gland, so ruled out anhidrotic
ectodermal dysplasia.
Ø Patient had
no history of psoriasis or other autoimmune disease or any trauma which can destroy sweat gland
and reduces perspiration.
Ø The only
possibility is, he might have embryological anomaly.
Ø Skin
grafting would not work, as problem is increasing with age.
Patient's HIPAA de-identified online-health-record with raw data and clinical images here
CASE-4
Experience:
65 year old woman complaining of
upper limb itching, pain on hip and thigh both side since 2 week.
She was apparently
alright 2 week back then she develops sudden itching at left upper limb near
elbow,soon develops macular lesion on it, which was easy, which cured on 2-3
days. On curing of it she develops weakness on both lower limb with pain on
thigh. She can walk almost normaliy but she was unable to stand from sitting
position. After 2-3 days of it she develops difficulty in swallowing with some
mass on left side of neck with mild pain.
Patient's HIPAA de-identified online-health-record with raw data and clinical images here
Reflection- patient had weakness on lower limb.
It might be neural or muscular.patient had no any other motor weakness like
normal reflexes, no muscle wasting. So most probably its due to some muscular
problem.
Conceptualization-
Ø Patient had mainly
weakness in thigh muscle indicate proximal myopathy.
Ø No signs like shawl sign
or any other typical lesion indicating dermatomyositis.
Ø Patient developed
difficulty in deglutination indicating pharyngeal muscle weakness.
Ø Patient developed itching
and macular lesion first which indicates some toxic origin.
Action-
Ø Thyroid level- as patient
showing fine tremor with tachycardia on examination, was increased.
Ø LFT- ALT AST was increased
and albumin was decreased.
Ø CREATININE KINESE LEVEL-
increased( 656u/l normal value is 26-192) indicating muscle distruction.
Ø MUSCLE BIOPSY- report was
normal.
Ø ENDOSCOPY- to rule out
oesophageal cancer as she developed deglutination difficulty on course of
disease.
Learning point-
Ø
After report of normal biopsy we had performed
deep cut biopsy on same sample if it is due to toxic origin then can involve
any layer of muscle on molecular level, but was also normal.
Ø
Performed endoscopy after complain of
deglutination difficulty to see for oesophageal carcinoma as patients all
complain might be paraneoplastic.
Patient's HIPAA de-identified online-health-record with raw data and clinical images here
CASE-5
Experience:
50 year old female complaining of recurrent
diarrhea with episodes stiffness of both hands since 2 year.
She was apparently alright 2 year
back. Then she develops recurrent diarrhea followed by stiffness of both hand,
which use to relieve by taking treatment by local physician. Patient is known
case of HYPERTENSION since 20 year.
Reflection-
after each episode of diarrhea patient might
developed electrolyte imbalance and calcium deficiency too, which leads to
tetany on both hand, which might relieved by calcium supplementation by local
physician.
Conceptualization-
Ø Patient is hypertensive since long, it affects kidney function or
hypertension might be due to renal origin.
Ø If pathology is in the adrenal it can cause
HYPERALDOSTERONISM which
causes hypertension along with electrolyte imbalance like hypocalcemia and
hypokalemia, which might be a cause of tetany.
Action-
Ø Haemogram- to rule out infections.
Ø Electrolyte levels- low calcium and low potassium.
Ø Aldosteron level- it was decreased.
Ø CT scan- left supra renal mass of approx 1.6x1.6 suggestive of
adrenal adenoma (CONNS SYNDROME)
Ø TREATMENT- can be managed by spironolactone oe patient may proceed
for follow up or surgical removal of mass.
Learning point-
Ø Patient with
hypertension should always rule out whether it is of adrenal origin.
Ø Renal
hypertension mostly accompanies with other symptoms of electrolyte imbalance
like tetany in this patient.
Ø Further management would be medical or surgical
will depend on the size of adenoma.
CASE-7
Experience: 25 year old man with pain
in all the joint and unable to open mouth since 12-13 year.
Apparently alright 13 year back. Then he develops pain on left
knee which gradually progress to right knee. With time it involve all the joint
of the body . patient is unable to open his mouth.
Patient's HIPAA de-identified online-health-record with raw data and clinical images here
Reflection-
patient has
severe deformity on hands and foot joint including wind swept deformity, swan
neck deformity, button hole deformity. It all are characteristic of rheumatoid
arthritis.
Conceptualization- patient have rheumatoid
arthritis since long. So it also involved temporo-mendibular joint too. That’s
why patient even unable to open his mouth properly.
Action-
patient has
clear clinical symptoms of rheumatoid arthritis, so no further investigation
has done for confirmation as it would load patient financially.
Main
focus was given to physiotherapy, so that patient can at least live his life
like normal individual.
With
the help of physiotherapy and surgery we put some effort on open his mouth, so
that he can eat properly.
Medical
management like intra-articular steroid as arthrocentesis can use for TMJ ankylosis.
Learning point- this case has proved that how necessary to treat a
case of rheumatoid arthritis . early intervention is very important as it may
involve TM joint too, which can worsen patients life further.
CASE-8
Experience:
22 year old man have
multiple pus discharging wound, severe weakness since 14-15 days.
He was apparently alright 15 days back. Then he develops abdominal
pain, not get relieved by taking medicine. On 2nd day of it he noticed
redness on his left thigh which progressively become wound with discharging
pus. It cured but wound developed on different parts of body with discharging
pus.
Patient's HIPAA de-identified online-health-record with raw data and clinical images here
Reflection- patient has developed
multiple subcutaneous abscess which discharging copious amount of pus
continuously. Patient is very thin cachexic but conscious responding to verbal
stimuli. He has no history of diabetes mellitus, trauma, insect or snake bite,
thorn prick.
Conceptualization- patient was working on
hotel. His symptoms starts with abdominal pain. He might acquired pathogen by
ingestion of unhygienic food which causing extensive septicaemia. Patient has
very low sugar level. He can not maintain his sugar level especially fasting
blood sugar, depends on IV dextrose.
Action-
Ø HIV status- negative
Ø Hepatitis B and C –
negative
Ø AFB staining- negative
Ø LJ serum culture- awaited
Ø Cell count- increase
polymorph(89), decreased lymphocyte(8), decrease monocyte(1), increased
platelet(4.62)
Ø Glucuse level – 30-50
mg/dl
Ø Patient is currently on cotrimoxazole.
Learning point-
Ø Patient is
probably on immunodeficient condition as he developed oral candidiasis and
oesophageal too as he develops odynophagia.
Ø Patient is
AFB negative, so possibility is cryptococcal or nocardia infection.
Ø Patient maintain
his glucouse level on repeated administration of dextrose which indicate renal
failure developed on short time.
CASE-10
Experience– 50 year female with…
1) Severe right sided frontal headache for 5 days.
2) vomiting of 1-2 episode for 1 day.
Patient's HIPAA de-identified online-health-record with raw data and clinical images here
Reflection – 1) Common causes of frontal headache…
· Frontal sinusitis
· Migraine
· Tumor
· Hypertension
· Sub acute angle closure glaucoma
Conceptualization-
i. Sinus openings are clear, so signs of sinusitis.
ii. No aura, no photophobia, no vertigo, so migraine is ruled out.
iii. No projectile vomiting no neck rigidity no meningeal signs.
iv. Normal blood pressure so no hypertension.
v. No H/O previous attack of raised IOPtill age, eye was not red no congestion, no eye pain and no other signs of glaucoma.
On 3rd day of admission, patient developed papulovesicular eruption on right forehead, right eye was closed due to inflammation, conjunctiva was congested.
Conclusion- patient developed HERPES ZOSTER OPTHALAMICUS which infiltrated trigeminal nerve. It mainly involved right eyelid and spares cornea.
Action- 1) tonometry and gonioscopy is done to rule out raised IOP.
2)CT head done to rule out raise ICT or any tumor.
3)fundoscopy done to rule out refractive error and papilloedema.
4) patient is on VALACYCLOVIR to overcome viral problem.
CARBEMEZEPINE for neuralgic pain.
LEARNING POINT--- TIP OF NOSE IS NOT INVOLVED YET, SO NASOCILIARY NERVE IS SPARED. SO THERE IS LEAST CHANCE OE INVOLVEMWNT OF CORNEA.
Patient's HIPAA de-identified online-health-record with raw data and clinical images here
