General Medicine Internship Real Patient OSCEs Towards Optimizing Clinical Complexity

 This is an a online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan

The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitted. 

C/o facial puffiness since 1 month

HOPI- 

Patient was apparently asymptomatic 1 month ago then she developed h/o fever which lasted for3-4days and relieved on medication,associated with h/o cough for 3-4days ,non productice ,non blood stained, relieved on medication .

After 10 days patient develeped facial puffiness during early mornings which relieved by evening.

Noh/o palpitations, sob, chest pain ,pedal edema, decreased urine output.

Past history- N/K/C/O HTN, DM, CVA, CAD, EPILEPSY, THYROID

PERSONAL HISTORY-  

SLEEP- adequate

BOWEL AND BLADDER-regular

No known food and drug allergies

No known addictions

Menstrual history-not attained menarche

O/E-patient was conscious, coherent, cooperative well oriented to time place and person

She is moderately built and nourished

Pallor, Icterus,Cyanosis, clubbing, lymphadenopathy, edema absent.

Vitals-

Temp: Afebrile 

PR- 101bpm    

RR- 20/Min

BP- 110/70 mmHg

SYSTEMIC EXAMINATION

P/A - Shape of abdomen- flat. No scars. No organomegaly. Bowel sounds heard.

CVS- S1 S2 heard, no murmurs

RS- NVBS.

CNS- No focal neurological deficits

Tone- RT. LT

UL. Normal. Normal

LL. Normal normal

POWER

UL. 3/5. 3/5

LL. 3/5. 3/5

Reflexes: right left  

Biceps 2+ 2+

Triceps 2+ 2+

Supinator 1+ 1+

Knee 2+ 2+

Ankle 1+ 1 +

Plantar present. Present

OSCE-

1.List all the complaints of the patient with respect to the history and relevant clinical data and mention the treatment plan for each listed problem and mention treatment plan stating it's efficacy in relevance to patient relief and better outcome. 

A) C/o facial puffiness since 1 month

PROVISIONAL DIAGNOSIS- NEPHROTIC SYNDROME

TREATMENT-

Protein powder 2 spoons in 1. Glass of water

2-3 egg whites per day

Tab wysolone 20 mg

2.What are the possible causes of facial puffiness 

A)  -Anemia.                    -renal disorders 

-Angioedema                 -hypothyroidism.                                  -Cushing syndrome       -cellulitis 

3. List out all relevant clinical investigations needed for this patient to make a probable diagnosis 

A)INVESTIGATIONS-

4.What is Nephrotic syndrome?criteria for diagnosing as nephrotic syndrome?

A) Nephrotic syndrome- It is a  primary glomerular disease characterised by-

Clinically-

-Facial puffiness

-pedal edema

laboratory investigations:

-PROTEINURIA(urine albumin 3+)

-LOW SERUM ALBUMIN(serum albumin <1.5g/dl)

-HYPER LIPIDEMIA

-LIPIDURIA

-SPOT UPCR(>4.6)

5.WHAT ARE TYPES OF NEPHROTIC SYNDROME?

A)In CHLIDREAN (MSTLY MCD-90%,OTHER CAUSES-FSGS,MN)

IN ADULTS(Most commonFSGS>MN>MCD>IG A NEPHROPATHIES>AMYLOIDOSIS)

6. WHAT IS NON NEPHROTIC PROTEINURIA?

A)  upto 150 mg /day proteinuria

 And upto 30 mg/day albuminuria is considered as non nephrotic proteinuria.

It can be seen in - non significant proteinuria(seen in anxiety,stress,menstrual cycles,high protein diet)   

Microalbuminuria(seen in diabetes and hypertension)      

 -overflow proteinuria(seen in -light chain myeloma)

-Tubular proteinuria(due to loss of B2tubulins in urine)  

  -orthostatic proteinuria(diagnosis of exclusion ,is a benign entity)

7.MCD?(MINIMAL CHANGE DISEASE)

A) IT is a type of podocytopathy.

In this there is increased expression of CD80 on podocytes and increased levels of angiopetide  that leads to loss of negative charge and leading to proteinuria.

Patient present with features of edema,selective proteinuria,hyper lipidemia,hyper liiduria.

8)what is treatment given?

A) steroid therapy has been started

Tab wysolone 20 mg (2------0------1), (8am   8pm).

Steroid therapy to be given for 6 weeks and then tapering of the dose over a period of 6 weeks)