MEDICINE INTERNSHIP

This is Prateek Pulgurti,a medical student from India. As an intern who worked in the general medicine department, I embarked on a transformative journey, witnessing challenges and complexities of patient care. In this platform, I will share the glimpse into my journey in the department and recount my experiences and lessons I gained during my time in the department.

CBBLE PAJR PARTICIPATORY LEARNING ACTION RESEARCH DISCLAIMER

NOTE: THIS IS AN ONLINE E LOGBOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS/HER GUARDIAN'S SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS INTENDING TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT.

CASE - 1

CHIEF COMPLAINTS

67 Year old male patient farmer by occupation was brought to the causality with

C/o difficulty in breathing since 20 days

C/o cough with sputum since 20 days

C/o weakness since 20 days

HISTORY OF PRESENT ILLNESS

The patient was apparently asymptomatic 2 years ago, when he developed gradual slowness in movements, gait disturbances and frequent falls.

20 days ago he developed difficulty in breathing which was sudden in onset and progressed gradually from Grade I MMrC to Grade III MMrC, with no diurnal or seasonal variation and no relieving or aggravating factors.

It is also associated with cough, productive, copious amount , white in colours, turbid, thick in consistency , not blood stained and not foul smelling.

H/o sudden fall on his back since 2 years due to loss of postural control.

Falls not associated with any giddiness, vertigo, tiredness, slippage and he was conscious after the fall.

He was taken to a nearby hospital , where a CT scan of the brain was taken and the report showed no abnormalities.

Since the first episode 2 years ago he started developing slowness in all his movements, initially started with the head and neck and has now progressed downwards to affect the lower limbs.

There is no h/o of wasting, thinning of the upper and lower limb muscles

No h/o of difficulty in brushing teeth, buttoning shirts, wearing slippers, getting up from the chair or sitting or sleeping .

He had a history of a similar fall 20 days ago , since which he has developed difficulty in brushing teeth, buttoning shirts, wearing slippers, getting up from the chair, sitting or sleeping .

Movements of the limbs are extremely slow and are not effective in completing any work.

Limbs are stiff and hard

No wasting or thinning

Able to feel clothes, hot and cold sensations

No tingling or numbness reported

No loss or alteration in the consciousness

No speech disturbances.

No delusions, hallucinations, emotional disturbances

No stiffness of neck , fever or vomitings

No h/o diarrhoea , abdominal pain

No h/o palpitations, chest pain

No h/o seizures

PAST HISTORY

K/C/O TB (resolved) underwent treatment 20 years ago

N/K/C/O DM/CAD/CVA/EPILEPSY

K/C/O HTN since 1 year on regular medication

K/C/O Asthma since 6 months and on regular medication

PERSONAL HISTORY

Sleep adequate

Bowel and Bladder - Regular

Appetite - Normal

Habits - Occasional Toddy Drinker

GENERAL EXAMINATION

The patient is conscious, coherent and cooperative

And well oriented to time, place and person

VITALS

Temp - 98.7 F

RR - 34 cpm

PR - 80 bpm

BP - 120/70 mmhg

Spo2 - 93 % on RA

No signs of Pallor, Icterus, Cyanosis, Clubbing or generalised lymphadenopathy

SYSTEMIC EXAMINATION

CVS - S1 S2 Heard, No Murmurs

RS - BAE +

PA - Soft / Non Tender

CNS Examination

The Patient is conscious

Higher Mental Status

Immediate - Intact

Implied - Intact

Long - Intact

GCS - E4V5M6

Right Handed

Neck Rigidity -

Brudzinsky - Negative

Kernig - Negative

Cranial Nerves

1 - intact

2 - intact

3 ,4,6 - Unable to ellicit

5 - Intact

7 - intact

8 - intact

9 - Intact

10 - intact

11 - intact

12 - intact

Joint Position - Intact in both limbs

Stereognosis - Intact in both limbs

Tremors - Intentional, sometimes resting

MOTOR SYSTEM

	Right	Left
Bulk	Normal	Decreased
Tone	Hypertonic	Hypertonic
Power	4/5	4/5

Reflexes

	Right	Left
Biceps	+	+
Triceps	+	+
Knee	+	+
Ankle	+	+
Plantar	Flexion	Flexion

OTHER FINDINGS

Slow Occular Saccades +

Gaze Palsy +

Masked Facies +

Serpentine Stare +

Hypophonia +

Bradykinesia +

Rigidity +

Myerson Sign +

CLINICAL IMAGES

MICKEY MOUSE SIGN - MIDBRAIN MRI TRANSVERSE SECTION

HUMMING BIRD SIGN - MRI SAGGITAL SECTION

PROVISIONAL DIAGNOSIS

PROGRESSIVE SUPRANUCLEAR PALSY (ATYPICAL PARKINSONISM)

[PARKINSON PLUS]

CASE-2

This is a case of 65yr old female ,home maker ,resident of Nalgonda came with c/o abdominal distension since 4 days

HOPI - She was apparently asymptomatic 10 days ago then she developed fever ,insidious in onset,low grade ,intermittent type,not associated with chills and rigor,no aggravating factors,relieved on medication,associated with body pains.

C/o vomitings since 10 days ,5-6 episodes with food particles as content ,non projectile ,non bilious ,non blood stained

C/o burning sensation in oral cavity since 10days(because of which she is unable to eat) ,no h/o dysphagia,loss of appetite and weight loss

Since 4 days c/o abdominal distension associated with belching,regurgitation of food ,aggravating on lying down after taking food and no relieving factors .

No h/o burning micturition ,headache,cold and cough

No h/o pain abdomen ,constipation or loose stools

No h/o sob,chest pain ,pedal edema and palpitations and decreased urine output.

K/C/O DM2 since 6years,on T.vildagliptin 50mg+t.metformin 500mg and HTN since 6years,on T.telma H.

On examination,

CVS:

s1,s2 heard ,no murmurs

RS:

BAE+,NVBS +

P/A:

distended ,umbilicus :inverted

Non tender ,no organomegaly

No shifting dullness and fluid thrill

Bowel sounds +

CNS:

No focal neurological deficits

Inference:

Based on the complaints,my provisional diagnosis is ?Acid peptic disease

To confirm the diagnosis,we advised endoscopy to the patient.

REPORT:

PROVISIONAL DIAGNOSIS:

Acid peptic disease-atrophic gastritis K/C/O DM and HTN since 6years

Treatment:

1.Tab.RAZO -D 40mg Po/OD before breakfast

2.Syp.sucrafyl-o Po/TID 15mins before food

3.Tab.telma -H 40 po/OD

4.Tab.vidagliptin 50mg+metformin 500mg BD

Learning points:

This case made me look into the etiology behind the acid peptic disease.

CASE-3

https://prateekpulgurti127.blogspot.com/2024/01/77m-with-parasthesia-all-over-body.html

This is a case of 77year old male came to the OPD with chief complaints of pricking sensations all over the body since 1 year.

COURSE OF EVENTS :

Patient is a farmer by occupation. He is uneducated and started working in the farms since his teenage. At the age of 25 years he got married(consanguineous marriage). After 2 years he lost his father due to? Seizure like activity.

After 2-3 months suddenly he experienced unknown fear, palpitations, chest heaviness, tingling sensations. He experienced tingling sensations initially over the head later extending on to the face, trunk and his limbs. He reports that he ran away 2-3 times from his home and he was found and brought back by his mother . When enquired why he ran away from his home he said that due to unknown fear, anxiety and palpitations he didn't like to stay back at home.( He reported that he didn't have any problem with his mother and she took good care of him).

He was not able to cope up from the death of his father. So his mother took him to many hospitals in warangal and hyderabad but it didn't help him. She took him to hospital in erragadda where he was treated for his symptoms. Patient was not compliant to medication. Later the patient used homeopathic medication but it also couldn't help him . He was later taken to some ayurvedic doctor and his symptoms subsided. During the start of his symptoms, his wife was taken away by her parents and she came back once he is completely alright. Initially he denied to accept his wife saying that the disease process might recur but he eventually accepted her.

He started farming again and lived happily with her wife. Next year his first child was born. He became the sarpanch of his village the same year and continued in the same post for 20 years. He managed his farming simultaneously.

8-9 years back he developed pain in the bilateral knee joints for which he was treated accordingly and the patient continued to use the treatment.

6 years back the patient felt mass per rectum not associated with any pain, no h/o bleeding per rectum.

He came to surgery opd in our hospital and was managed conservatively.

Since 1 year the patient started experiencing pricking sensation initially over the head, later over face and entire body. There are no aggravating factors and slight relief on scratching. Patient reports that his sleep was inadequate due his symptoms but once slept he couldn't feel any pricking sensations. His appetite was normal. He didn't isolate himself from work or any social gatherings because of his symptoms. It didn't interfere with his daily activities. He is worried that his symptoms are reoccurring.

Patient was taken to multiple hospitals and reported that many investigations were done and they all came out to be normal.

He was diagnosed to have hypertension and started on tab. Telma 40 mg and he is using his medication regularly for the past 1 year. He is not going to work for the past 1 year due to his knee pains.

In one such hospital visit 5 months ago, he is diagnosed to have cyst in his kidney for which surgery was performed (no documentation available) .

Sensory Examination-

Right Left

Spinothalmic

1. Crude touch- + +

2. Pain- + +

3.Temperature- + +

Posterior Coloumn

1. Fine touch + +

2.Vibration

-olecranon

process. 55 55

-styloid

process 75 65

-shaft of

tibia 85 55

-medial

malleous - -

3. Joint Position- UL 8/10 LL 8/10

UL 8/10 LL 8/10

Cortical

Graphaesthia- + +

Stereognosis- + +

Tactile locatlisation-+ +

MOTOR EXAMINATION

Tone

UL- N N

LL- N N

Power

UL- 5/5 5/5

LL- 5/5 5/5

Reflexs

B + +

T + +

S - -

K + +

A - -

Plantars Flexion Extension

Nystagmus- absent

Finger nose incordination- No

Knee heel test- able to do

Rhomberg’s test - No swaying

Dysdikokonesia - able to do

Provisional Diagnosis-? Parasthesia under evaluation with k/c/o HTN since 1yr

Treatment-

1. Tab.Gabapentin-M PO/OD

2. Tab.MVT PO/OD

3. Tab. Telma-40mg PO/OD

4. Montior Vitals 4th hrly.

CASE-3

This is one of the cases,I came across during my rotation in the nephrology ward.

https://prateekpulgurti127.blogspot.com/2024/01/65yr-old-female-with-apd-and-ckd-stage.html

https://prateekpulgurti127.blogspot.com/2024/01/a-30-year-old-female-with-complaints-of.html

Learning points:

I gained insights into the renal physiology and understood how hemodialysis plays a crucial role in supporting these functions.

I learnt the importance of patient monitoring during the dialysis sessions including vitals,fluid status and the risk of potential complications.
I got the opportunity to learn how to acquire the vascular access for hemodialysis.

I gained the experience in educating the patients about their conditions,the dialysis process and the need for lifestyle modifications with this condition.

CASE-4

This is a case of 35 year old female who came to OPD for the further treatment of her condition as she was already diagnosed as anemic, with the help of my residents we diagnosed that the anemia was secondary to menorrhagia by taking detailed menstrual history.

https://prateekpulgurti127.blogspot.com/2024/01/a-35-year-old-female-with-fever-and.html

CASE-5

This is a case of 49 year old male with abdominal pain.

https://prateekpulgurti127.blogspot.com/2024/01/49-ym-with-pain-abdomen.html

The diagnosis of the above case is acute pancreatitis as the serum amylase and serum lipase levels are higher the normal limits.
In this case,alcohol plays as a significant risk factor for the condition.The excessive alcohol consumption can lead to pancreatic inflammation,contributing to development of this condition.
The main area of treatment in this particular case is abstinence from alcohol,which is crucial to prevent further damage and reduces the risk of recurrence.
This case made me look into the causes, classic symptoms,significance of serum markers,treatment strategies associated with the condition.

CASE-6

https://prateekpulgurti127.blogspot.com/2024/01/a-39-year-old-male-with-cough-and-fever.html

With the help of my post graduates, I learnt the symptoms and signs associated with the various respiratory conditions.
I got to know how to perform thorough physical examination to identify the clinical conditions and also the importance of imaging studies like x-ray and ultrasound in confirming the presence of such conditions.

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PROCEDURES PERFORMED