Hello all. I am an intern in Medicine and one of the important terms of getting the internship completion is to complete my log book with my daily log of what I learn during the course of my duties from my cases, the procedures that I do as well as the theory questions and discussion that I engage in.
My daily schedule for the week is detailed here https://docs.google.com/document/d/1lCU31w0ir_ MBsJpLTFdyD9Dt1elAq9nDuwu0hfbc Z6k/edit?usp=drivesdk&ouid= 106211649452385508461 Our professor tells me that I need to log and record everything that I do and learn in the ward under three headings1) Cases seen that day2) Procedures seen or done that day3) Theory topics learned that daySo here goes starting from:Monday:Got a bit late for the morning rounds and my senior PG was not happy about that as she had to collect some reports on my behalf.Just saw this patient admitted yesterdayCase report:A 35yr old woman had presented with complaints of vomitings, 3 episodes 6 days back followed by altered sensoriumno h/o traumano involuntary movementsno h/o deviation of mouthno h/o fever,cough,chest pain,tremors,orthopnea,pndno h/o use of anticoagulants,oral contraceptive pillspast history:h/o intermittent headache.known case of tb 4yrs back ,took ATT for 6 months.no h/o HTN,DM,CVA,CAD,SIZURES.surgical history negative.On general examination I found:Pallor presentIcterus negativeNo cyanosis clubbing lymphademopathy,Edema.Mild dehydration and malnutrition present .Bp 100/60 mmhgPr 110 bpmspo2 96%temp 102FRR 20cpmGrbs 119 gm/dlCvs s1 s2 hears no murmursRs bae + nvbs hearsP/a soft ,nontender,bowels sound heard,On CNS examination in her HMF higher mental functions she appeared unconscious andstuporousspeech- no responseMMSE- not elicitedcranial nerves-1st not elicited2nd not elicitedrt lf3rd,4th,6thpupil size. N NDLR/CLR. N. NNO pstosis, nystagmus.5th sensory not elicitedmotor not elicitedreflex corneal normal,conjuctival normal7th motor nasolabial fold normalno deviation of mouthsensory not elicitedreflex corenal and conjuctival normalsecretomotor moistness of eye and tongue normal,buccal mucosa normal8 the nerve:Rinnes and Weber's not elicited9and 10 th nerve: uvula centrally placed,gag reflex present11 th nerve: trapezieus not elicited, sternocleidomastoid not elicited12 th nerve: tongue tone normal, no wasting, no fibrillations,no deviation of tongueMOTOR SYSTEMRight. LeftBulk: normal. NormalTone: ul. decre. NormalLL. Decre. NormalPower Ul 0/5. 3/5LL. 0/5. 2/5Reflexes.Superficial reflexesRight. LeftCorneal. P PConjunctival P. PAbdominal. P. PPlantar increase. WithdrawalDeep tendon reflexesRight. LeftBiceps. ++ ++Triceps. N. -Supinator. -. -Knee - -Ankle. - -Primitive reflex -absentInvoluntary movements - absent ( chorea,ballismus - negative) but left lower limb continuous / intermittent movements positiveSENSORY SYSTEMnot elicitedPain present in all four limbsCEREBELLUMtitubation - absentNystagmus- absentIntensional tremors - absentPendular knee jerk - absentCoordination test not doneMENINGIAL SIGNSNeck stiffness - positiveKernigns sign - negativeBrudzinkis sign - negativeSee here for a video of the clinical examination findings.INVESTIGATIONSHBS AG: negativeANTIHCV ANTIBODIES: nonreactiveHIV : non reactiveHEMOGRAM :28/4 29/4. 1/5. 3/5HB 5.4 6.3. 7.1. 9.4Platelets 1.94. 0.31. 1.11. 1.5TLC 12000PT. 20. 16INR. 1.7. 1.1APTT. 34TO.BIL. 1.03. 1.48DI.BIL. 0.27. 0.33SGOT. 17. 20SGPT. 8.8. 12ALK.PH. 68. 64TO.PRO. 7. 7.1ALB. 4.1A/G RATIO. 1.37RFTUREA. 17. 52CREATININE. 0.89. 0.8URIC ACID 2.6CALCIUM. 10.5PHOS. 4.2SODIUM. 146K+. 3.6CL-. 1002 packs of RDP and 1pack of PRBC transfused on 30/4/20
Her cranial MRI images are here below and we had a lot of confusion around it and will appreciate your inputs in the comment box:
I checked the TREATMENT chart and found that my senior had written:1)Head end elevation4)INJ.NEOMOL 1 g IV.( if temp is more than 102F)5)TAB.PCM 650 mg RT TID6) INJ.ZOFER 4mg IV.SOS7)TAB.VITAMIN C 500 mg RT OD8) TAB. B COMPLEX RT OD9) TAB.ATORVASTATIN 40 mg RT11) SYP.LACTULOSE 10 ml RT TID12) NEB WITH MUCOMIST 6 TH HOURLY followed by oral suctioning.13) PROPPED UP POSITION14) RT FEEDS 2ND HOURLY MILK 30ml1 HOURLY WATER 150ml15)I/O CHARTING16)GRBS CHARTING 6TH HOURLY17)BP ,PULSE ,SPO2 ,RRMONITORING18) AIR BED19)DVT STOCKING20)FREQUENT CHANGE OF POSITION 2NDHOURLY21) TEMPERATURE CHARTING 6th hourly.I asked her why were we giving her vitamin C and b complex following which she became angry so I thought maybe it wasn't required and she was angry with my finding fault with her inspite of having come late myself. I also wondered if the air bed and stockings were necessary. Again I wondered what could be the reason for her fever and why weren't we treating it with antibacterials to which she replied why was I thinking of bacteria and I asked if she had noted her WBC counts. They were 21,000 to which she said I was supposed to get the reports on time.Procedure:My senior PG medicine thought she had a right pleural effusion on examining her clinically and asked me to get an ultrasound guided pleural tap so that we could rule out a parapneumonic effusion as a possible reason for her fever.I took her to my radiology senior and she reported it was very mild and she wasn't sure if we could get any significant fluid there although she would try. I watched as she cleaned the posterior intercostal spaces and percussed in the most dull space and then put her USG probe in the tenth space which she thought was dull and showed me a thin rim of anechoic area around the lungs suggestive of pleural fluid. However once she inserted a sterile syringe needle she couldn't pull out any fluid and we had to abandon the procedure. (click here for the video)In the afternoon from 2-4 we presented this case to the entire department. See video here. https://youtu.be/fx4Kygh6Nqc We had a fruitful discussion on the case where the diagnosis of pure hematoma to explain the intracranial space occupying lesion in her left basal ganglia area was contested and alternate differentials were discussed.In the same session we also had a few topic discussions that I reviewed again for my NEET MCQs. Check out the video here https://m.youtube.com/watch?v=yhXqgGpfIEo&list= PLvOgc9_v4PCKsIrVK4laA3_ rUJOMPAYKJ One such topic (check out the specific video here:https://youtu.be/2wBfscoXjGg)
was about multiple myeloma where I learned about why the alkaline phosphatase would be normal in multiple myeloma (inspite of having osteolytic lesions and bone pain and I quote from the article linked below:"In Multiple myeloma, the myeloma cells activate the osteoclastic activity and suppress the osteoblastic activity through molecular pathways.Osteoblastic activity is seen by increased alkaline phosphatase and osteocalcin levels.Osteoclastic activity is seen by increase in collagen degradation product levels.Since the osteoblastic activity is suppressed by myeloma cells due to a mechanism which is not yet clearly known, serum ALP levels are either normal or decreased."The above article was actually shared by a final year PG which I have put as my own E logHere is the detailed MCI guideline based rationale for our daily roster
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