BIMONTHLY GENERAL MEDICINE ASSESSMENT
QUESTION 1:
LONG CASE:
This is primarily a case of Acute glomerulonephritis, likely due to Secondary Amyloidosis due to Chronic Poorly Treated Seronegative Erosive Rheumatoid Arthritis. The patient presented with bilateral, symmetric, pitting type of edema which was extending upto the middle of his leg. The patient also had chronic pain in the joints leading to restriction of movement since 2011. Upon previous hospital visits, the RA factor was negative. Therefore, the patient was prescribed analgesics and sent home. Chronic use of analgesic drugs was seen from 2011-2019, the details of which were undocumented. Hyperuricemia was also observed in one of his recent visits during last year and Febuxostat was prescribed as it has proven to be more effective than Allopurinol in recent studies. Anasarca was the chief complaint of this visit for which through testing and examinations were done. Liver and cardiac causes were ruled out and renal pathology seemed most obvious. Pre and post renal causes were also ruled out from the absence of volume loss (vomiting, diarrhea, diuretic abuse or burns) and no history of acute retention of urine or lower urinary tract symptoms. The presence of frothy urine and edema strongly supports a glomerular pathology due to significant loss of protein and also decreased urine output. Isolated defects in tubular/interstitium are unlikely as such patients have a deficit in maintaining urinary concentration, which causes polyuria. Such a high range of proteinuria causing anasarca is also not seen with tubular/interstitial pathologies alone. It was advised that quantifications of the renal function would help determine the underlying disease. The tests suggested severe proteinuria with very low albumin and elevated creatine. Electrolyte imbalance was also seen. After thorough examinations, it was concluded that the patient was seronegative for rheumatoid arthritis but the erosive joint damage, movement restriction and the patient of damaged joints suggested that the patient in fact has Rheumatoid arthritis. A review of literature showed that sensitivity of RA factor for Rheumatoid Arthritis was 28% and specificity was 87% which supports the above theory. The likeliness of a false negative is high for the RA factor test. Co- existence of rheumatoid arthritis and gout is not that common but evident. Some other co-existing problems were dilutional hyponatremia and anemia of chronic disease are secondary to the final diagnosis. If the possibility of seronegative RA was considered in earlier hospital visits, the patient could have avoided the pain and inconvenience caused by secondary amyloidosis. The patient was examined thoroughly and every other possible diagnosis was considered and ruled out systematically. The approach was evidence based and the case was handled excellently. The presentation covered all the aspects of the case and all significant symptoms and possibilities were explored. Necessary thought was given to the important aspects and treatment was given on the basis of literature and efficacy of the drug compared to the traditional alternatives. In my opinion, there isn't a better way to go about this case than what was followed above.
SHORT CASE 1 :
This is a case of idiopathic Parkinson’s Disease. The patient presented with progressive asymmetric involuntary movements of his right index and middle fingers which progressed to micrographia and stiffness in range of motion. Shuffling gait and impaired balance observed. The cause of this disease remains unknown throughout the case, hence idiopathic. The patient has never consumed alcohol or smoked. The basal ganglia disease was differentiated from cerebellar disease through systemic examination of symptoms pertaining to cerebellar disease such as drunken gait, dysdiadokinesia and Romberg’s test, etc. Absence of meningeal signs. Autonomic impairment was seen as postural hypotension and erectile dysfunction. Upon CVS examination, sinus tachycardia and grade II diastolic dysfunction. Appropriate procedure was followed and proper treatment was given. The case was handled nicely. Timely intervention was done, therefore the patient was able to return home after appropriate care was given.
SHORT CASE - 2
This is a case of Iatrogenic cushing's disease. The patient developed lesions pertaining to ring worm a year and half ago, he visited a local RMP who gave Ayurvedic treatment which included several creams and tablets of unknown composition along with topical clobetasol ointment for a year which is estimated to have been the cause of Cushing's disease. All classic signs of cushing’s disease were observed such as buffalo hump, reddish purple striae, sparse scalp hair , easy bruising moon face, abdominal distension(pot belly) etc. There was a co-existence of cushings with a tinea corporis( ringworm) infection causing multiple itchy ring lesions. The patient was referred to dermatology for skin lesions , ophthalmology for visual acuity and cataracts and orthopaedics for lower back pain. Dermatology prescribed antifungals and fusidanes which have steroid-like structure. Ophthalmology determined an increased IOP and follow up was advised. The patient was sent for psychiatric consultation and was diagnosed with moderate depression and counselling was given. During the course of treatment, the patient tested positive for COVID-19. Treatment for COVID-19 was given and recovered within a week. The treatment for cushing’s and ringworm was advised to be continued. Calcium supplementation was given for lower back pain. Adequate treatment was given and the patient was able to recover as expected. Due to alternative treatment and unmonitored steroidal application, a simple case of ringworm turned into full blown cushing's disease which could have been avoided had adequate care been given in the first place. The patient was able to return home after adequate treatment after proper investigations and treatment by the attending doctor.
QUESTION 2:
LONG CASE:
Acute Glomerulonephritis due to Secondary amyloidosis
Presenting symptoms:
Secondary Hypertension
Oliguria (360 ml urine in the last 24 hours)
Hypoalbuminemia (Serum Albumin 2.5g/dl) and Anasarca
Dysmorphic RBCs in Urine
Chronic Poorly Treated Seronegative Erosive Rheumatoid Arthritis.
This patient has >10 joints involved with multiple small joints involvement - 5 points; Symptom duration 10 years - 1 point; RA Factor - NEGATIVE; CRP elevated & ESR - 120 mm/hr - 1 point; Total Score - 7/10
A review of literature showed that sensitivity of RA factor for Rheumatoid Arthritis was 28% and specificity was 87%. For non RA rheumatological disorders, the sensitivity was 29% and the specificity was 88%. Sensitivity pertains to false negative rate and specificity pertains to false positive rate. The sensitivity data reveals that it is highly likely for a false negative to appear but not high enough for a RA factor to be removed as a diagnostic test.
Dilutional Hyponatremia secondary to Anasarca due to Glomerulonephritis
The glomerular disease caused widespread damage to the glomerular membrane which led to the electrolyte imbalance and generalised edema was caused due to decreased COP by proteinuria.
Hyperuricemia likely due to decreased Uric Acid Excretion Precipitating Gouty Arthritis
Coexistence of gout and RA isn't uncommon.
Anemia of Chronic Disease secondary to Poorly Treated Rheumatoid Arthritis.
SHORT CASE 1
Idiopathic Parkinson's Disease Stage 1 with denovo HTN.
All the significant symptoms of parkinsons were observed such as tremors , uncoordinated repetitive movements , shuffling gait, micrographia,etc,
Multiple System Atrophy - Parkinsonian Type (MSA-P).
Damage to the dopaminergic pathways causes decreased inhibition of movements which also causes stiffness of various movements and leads to atrophy as usual coordination does not take place.
SHORT CASE 2
Iatrogenic cushing’s disease due to topical application of clobetasol for over 1 year.
Unmonitored use of steroids leads to several complications mainly cushing’s disease also known as hypercortisolism. There has been significant evidence that corticosteroids show improvement in treatment of skin diseases but it is to be regularly monitored as adverse effects upon improper use are common.
Tinea corporis
Ringworm infection causing multiple ring lesions over various areas which can be treated fairly simply by antifungals.
QUESTION 3
LONG CASE
Although glomerulonephritis is rare in the general population it is the second most important
cause for end-stage renal failure. The therapy of glomerulonephritis is guided by a limited number of individual clinical
trials and treatment recommendations are based on meta-analysis and Cochrane Systematic Reviews. The impact of
such therapy standards on the prognosis of glomerulonephritis is not known. Methods: Between October 2002 and De-
cember 2008 patients with abnormal urine findings and/or decreasing renal function of unknown cause were referred for
renal biopsy. In a collaboration of out-patient nephrologists with a major teaching hospital, all patients received treat-
ment recommendations according to evidence-based therapy guidelines based on Cochrane Systematic Reviews. Patient
charts were systematically reviewed and patients were re-examined for follow-up until November 2009. Cox Regres-
sion analysis was performed to identify independent prognostic factors. Results: Two hundred patients with primary or
secondary glomerulonephritis were identified. Complete follow-up data were available from 196 patients with 324
therapeutic interventions. The mean follow-up was 2.8 ± 2.0 years. Among all patients, 37% remained unchanged ill,
13% died, 17% had progressing renal disease, while 19% had a complete and 14% a partial remission. Proteinuria de-
clined in primary glomerulonephritis (5.0 ± 5.4 g/d to 2.1 ± 3.4 g/d, p < 0.001) and secondary glomerulonephritis (4.8 ±
4.6 g/d to 2.7 ± 3.1 g/d, p = 0.004). The highest rates of remission were observed in minimal change disease (83%) and
membranous nephropathy (50%). Survival was lowest in MPGN and secondary rapid-progressive glomerulonephritis
(33% and 50%, respectively). 70 (22%) interventions were complicated by adverse events resulting in treatment cessa-
tion in 25 cases. Cox univariate analyses identified the following parameters to improve outcome: Histology, no tubu-
lointerstitial fibrosis, primary glomerulopathy, absence of hypertension at presentation, diabetes, ischemic heart disease,
no diuretics or insulin, serum creatinine < 175 µmol/l, blood pressure < 160 mmHg, age < 60 ys, prednisolone, cyc-
losporin A, azathioprine, and follow-up by 24 hr urine. In a multivariate forward Cox regression analysis, tubulo-inter-
stitial fibrosis had a hazard for the combined end-point of death, dialysis and progression of renal failure of 4.4 (95%
confidence interval (95% CI: 1.8 - 10.6) while intensive follow-up by regular 24 hr urine collections reduced the risk to
0.3 (95% CI: 0.1 - 0.7), treatment with prednisolone had a hazard of 0.3 (95% CI: 0.1 - 0.9), and cyclosporin A therapy
a hazard of 0.2 (95% CI: 0.02 - 1.4). Application of Cochrane review based therapy guidelines along with intensified
monitoring of renal function prolonged dialysis-free survival by 1.7 years. Conclusions: In a multivariate model of
standardised glomerulonephritis therapy the presence of tubulointerstitial fibrosis was associated with death or progress-
sive renal disease, while prednisolone-based therapy regimens and intensified nephrological follow-up resulted in a sig-
nificant delay of endstage-renal failure. This result should direct future health care policies because glomerulonephritis
accounts for nearly 20% of the dialysis population
SHORT CASE
Objective: The objective of this review was to update evidence‐based medicine recommendations for treating motor symptoms of Parkinson's disease (PD).
Background: The Movement Disorder Society Evidence‐Based Medicine Committee recommendations for treatments of PD were first published in 2002 and updated in 2011, and we continued the review to December 31, 2016.
Methods: Level I studies of interventions for motor symptoms were reviewed. Criteria for inclusion and quality scoring were as previously reported. Five clinical indications were considered, and conclusions regarding the implications for clinical practice are reported.
Results: A total of 143 new studies qualified. There are no clinically useful interventions to prevent/delay disease progression. For monotherapy of early PD, nonergot dopamine agonists, oral levodopa preparations, selegiline, and rasagiline are clinically useful. For adjunct therapy in early/stable PD, nonergot dopamine agonists, rasagiline, and zonisamide are clinically useful. For adjunct therapy in optimized PD for general or specific motor symptoms including gait, rivastigmine is possibly useful and physiotherapy is clinically useful; exercise‐based movement strategy training and formalized patterned exercises are possibly useful. There are no new studies and no changes in the conclusions for the prevention/delay of motor complications. For treating motor fluctuations, most nonergot dopamine agonists, pergolide, levodopa ER, levodopa intestinal infusion, entacapone, opicapone, rasagiline, zonisamide, safinamide, and bilateral STN and GPi DBS are clinically useful. For dyskinesia, amantadine, clozapine, and bilateral STN DBS and GPi DBS are clinically useful.
Conclusions: The options for treating PD symptoms continues to expand. These recommendations allow the treating physician to determine which intervention to recommend to an individual patient.
SHORT CASE
Objective: The objective is to formulate clinical practice guidelines for treating Cushing's syndrome.
Participants: Participants include an Endocrine Society-appointed Task Force of experts, a methodologist, and a medical writer. The European Society for Endocrinology co-sponsored the guideline.
Evidence: The Task Force used the Grading of Recommendations, Assessment, Development, and Evaluation system to describe the strength of recommendations and the quality of evidence. The Task Force commissioned three systematic reviews and used the best available evidence from other published systematic reviews and individual studies.
Conclusions: Treatment of Cushing's syndrome is essential to reduce mortality and associated comorbidities. Effective treatment includes the normalization of cortisol levels or action. It also includes the normalization of comorbidities via directly treating the cause of Cushing's syndrome and by adjunctive treatments (eg, antihypertensives). Surgical resection of the causal lesion(s) is generally the first-line approach. The choice of second-line treatments, including medication, bilateral adrenalectomy, and radiation therapy (for corticotrope tumors), must be individualized to each patient.
QUESTION 4
https://146venkatameghanabadam.blogspot.com/2021/08/146-meghana-gm-aki-2-to-acute-ge.html
QUESTION 5
The Pandemic has for the first time compelled medical students to stay back at home for months together during their course of MBBS.
During the second wave of COVID ,which is still on at present , I got stuck up at home while being in the Second year of my MBBS course
Due to this pandemic ,as we know there are thousands of people infected with the deadly virus but not having the privilege of being checked upon by a doctor ,or of being allocated a bed and an oxygen cylinder in the vicinity.
All these have now become more common.
The other side of the sad story is that there are number of other patients who do aren't suffering from COVID but this lockdown, and the scare of hospitals and clinics being infected , have prevented these people from getting even bare minimum of consultations for their varied other pathologies, be it a chronic or an acute one.
It would be great if there are offline postings for our batch which is more helpful to understand the cases more in a better way.
The interns who have passed the information regarding patients in a deidentified way to make blogs in the appropriate method; we also learned to take history in the past 2months.
The HOD of the GM department has made classes very interesting despite the pandemic and I thank Dr. Rakesh Biswas sir for this wonderful opportunity.
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