4.Case-based OSCE along with Bloom's learning levels achieved

Case-based OSCE along with Bloom's learning levels achieved.


I am Kasarabadha Sampath ,Intern from 2k18 batch.


OSCE:

IP case 

There is a 78 year old female lying in first bed of  ICU .

This is my IP Case

Blog:

https://kasarabadhasampathrollno71.blogspot.com/2023/09/blog-post_20.html


Chief Complaints:

Inability move and loss of speech since 1 month


HOPI:

Patient was apparently asymptomatic 1 month back then she fell in her daughter’s house and was found unconscious,after the fall she wasn’t able to talk and move.She was taken to a local doctor and was treated for 3 days but the symptoms did not subside. Then she was taken to a private hospital where CT brain was done and was diagnosed as Ischemic stroke .Due to financial issues she was shifted to Government hospital where she was treated well, after that she was able to walk with support and her speech gradually improved and was discharged with medication. After coming home she was not able to take medication properly, her symptoms were getting deteriorated and then she came to our hospital .

No History of Fever ,Cough,Vomting.

No History of Chest pain ,SOB.





Past History:

K/C/O  Hypertension since 4 years on tab Amlodipine  5mg Once daily.

Not a known case of DM,CVA,CAD,TB,Asthma,Epilesy,Thyroid disorders.


Daily Routine:

She wakes up at 5 AM in morning,she goes for walking for one hour ,she has breakfast at 8:00 AM  then she help her daughter in household work,they have their lunch at 1 :00 PM then she takes rest till 4 PM then she  goes for walking for one hour and comes to home, Dinner at 8:00 PM , then goes to sleep by 9:00 PM.


Personal History:

Diet: Mixed

Appetite:Normal

Sleep: adequate 

Bowel and bladder: regular.

No addictions.


General physical Examination:


Pallor,Icterus,clubbing,cynosis,lymphadenopathy ,edema absent


VITALS:

TEMP: 98.4F

BP: 100/60 MM/HG

PR: 102 BPM

SPO2: 97%

RR: 20CPM.


CNS EXAMINATION:


Higher mental functions:

Patient is conscious but irritable 

Speech :slurred 

Language: Can’t understandable 


CNS:- 


Tone 

             Right                     Left 

U.L   N.                           Increased

L.L.   N.                           Increased 


Power 

        Right   Left 

U.L    3/5.    3/5

L.L.    3/5.    3/5


Reflexes 

         Right     left 

B        ++.         ++

T.       ++.          ++

S.       -              

K.        ++.       ++ 

A.              -          -


PLANTAR:- flexor.    Extensor


Sensory system:  not able to examine as patient in altered sensorium 


Signs of Meningeal Irritation:

Neck stiffness: absent 

Kernig’s sign :absent

Brudzinski’s sign:absent


PER ABDOMEN-

Soft,non tender,No organomegaly


CVS:

S1 S2 heard , No murmurs


RS:

BAE present,Normal Vesicular Breath Sounds present.



Diagnosis:

Altered sensorium secondary to ?chronic ischaemic stroke,Atrial Fibrillation secondary to ?CAD  with Heart failure  preserved ejection fraction secondary to CAD.


Investigations:


Hemogram:


HB:12.2 gm/dl

TLC :6900 cells/cu mm

RBC :4.29  million/cu mm

Platelet count:3.0  lakh/cu mm


RFT:


Urea:- 37 mg/dl

Creatinine:-0.9 mg/dl

Sodium:- 140 mEq/L

Potassium:-4.2 mEq/L

Chloride:- 102 mEq/L


LFT:


Total Bilirubin 1.17 mg/dl

Direct Bilirubin 0.86 mg/dl

ALP -150 IU/L

TOTAL PROTEINS:- 7.7 gm/dl


Serology: negative 


Treatment:

1.INJ NORADRENALINE @4ml/hr IV INFUSION INCREASE OR DECREASE ACCORDING TO MAP 

2.INJ MONOCEF 1 gm  IV/BD

3. INJ HEPARIN 5000 IU IV/QID 

4. TAB ECOSPIRIN AV (75/20) RT /HS 

5. INJ AMIODARONE 6mg/ml @ 6.3 ml/hr 

6. SYP POTKLOR 15 ml in one glass of water 

7. Monitor vitals hourly


Levels of Blooms:


Level 1:Remembering


It is basically What happened and how did it happened? Usually we get to know about it through history :


Patient was apparently asymptomatic 1 month back then she fell in her daughter’s house and was found unconscious,after the fall she wasn’t able to talk and move.She was taken to a local doctor and was treated for 3 days but the symptoms did not subside. Then she was taken to a private hospital where CT brain was done and was diagnosed as Ischemic stroke .Due to financial issues she was shifted to Government hospital where she was treated well, after that she was able to walk with support and her speech gradually improved and was discharged with medication. After coming home she was not able to take medication properly, her symptoms were getting deteriorated and then she came to our hospital .

No History of Fever ,Cough,Vomting.

No History of Chest pain ,SOB.


Past History:

K/C/O  Hypertension since 4 years on tab Amlodipine  5mg Once daily.

Not a known case of DM,CVA,CAD,TB,Asthma,Epilesy,Thyroid disorders.


Level 2:


Understanding:


Understanding her problem and classifying according to findings:




Atrial Fibrillation:





https://www.ncbi.nlm.nih.gov/books/NBK526072/






Level 3: Applying 

Proper investigations done.

https://www.ninds.nih.gov/health-information/disorders/atrial-fibrillation-and-stroke





Level 4:Analyzing 


-How to differentiate altered sensorium due to organic cause and inorganic cause?



While organic illnesses are characterized by physical and biochemical signs, non-organic disorders manifest only distressing experiences (as pains or anxiety) or undesirable behaviour (as abuse of alcohol)--phenomena that are inseparable from normal sensation, emotion, intentions and actions. As for treatment, the main methods applied in organic illnesses are of a physical and biochemical nature.







-How stroke cause altered sensorium?


Acute decline in sensorium is a commonly encountered symptom in the neurocritical care units, the differential for which is enormous. The causes may range from easily reversible (such as hypoglycemia) to relatively permanent (such as stroke), and from benign (such as intoxication) to potentially life threatening (such as meningo-encephalitis) etiologies. A streamlined approach to such patients is necessary for a systematic diagnostic workup and appropriate management. 


The fall in sensorium is due to a diffuse neuronal dysfunction caused by a decreased supply of glucose and oxygen to the brain, from either structural or non-structural brain diseases. Structural causes of a decline in sensorium include those that cause focal pressure in the brain, ultimately blocking substrate delivery at the cellular level. They include – trauma (subdural or epidural hematoma), brain tumors, intracranial hemorrhage, hydrocephalus, vascular occlusion etc. Patients with a decline in sensorium due to a structural cause usually have asymmetrical neurological findings, such as anisocoria, hemiparesis, asymmetric eye movements etc. An urgent imaging (computed tomography, CT head) is required to exclude a potential herniation syndrome or stroke, that need urgent intervention.




LEVEL 5 - EVALUATING


Problem list:


Altered sensorium secondary to ? Stroke 


Atrial fibrillation .




OP cases


Case 1:


A 52 year old  male farmer by occupation came to OP with cheif complaints of passing of mucus discharge from anus since 1 month


HOPI:

Patient was apparently asymptomatic 1 month back then he developed passing of mucus discharge from anus which is not associated with stools.

H/o Loose stools  intermittently since 1 month watery, not associated with blood.

No H/o pain abdomen,Nausea,Vomiting.

No H/o Burning micturation.


Past History:


Knowing case of DM type 2 since 10 years on Metformin 500 mg.

Not a known case of HTN,TB,Epilepsy ,CVA,CAD,Asthma.


Personal History:

Diet: Mixed

Appetite:Normal

Sleep: adequate 

Bowel and bladder: irregular.

No addictions


General Examination:


Pallor,Icterus,clubbing,cynosis,lymphadenopathy ,edema absent


Vitals:

BP:110/80mm hg

PR: 78 bpm

Temp:afebrile


PER ABDOMEN-

Soft,non tender,No organomegaly


CVS:

S1 S2 heard , No murmurs


RS:

BAE present,Normal Vesicular Breath Sounds present.


CNS:NAD


Per rectal examination:


No anal tags

No active fissure

No external hemorrhoids

No evidence of any fistula or sinuses

Anal tone:Lax

About 2 * 8 cms growth noted .

Hard in consistency,non moblie,?bleeds on touch


Diagnosis:? Carcinoma rectum


Adviced colonoscopy with biopsy, MRI pelvis.



Case 2:


A 66 year old  female who is home maker came to  opd for general checkup.


HOPI:

Patient was apparently asymptomatic 10 years back then she was diagnosed as Hypertensive   During her general health check up 10 years back. She is on Amlodipine 2.5 mg  once daily.

Few days back, as a part of general checkup ECG Showed MI changes.

No C/o chest pain, palpitations,SOB,sweating.


Past history:

Known case of Hypertension since 10 years on amlodipine 2.5 mg.

Not a known case of DM,TB,Epilepsy ,CVA,CAD,Asthma.


Daily Routine:

She is a House wife, she wakes ups at 5AM in the morning, she engages in some spiritual activities (prayers) from 5AM to 7 AM .Then she does her daily household work and she has breakfast at 8:30 AM . She usually has upma ,Idilli,Dosa, for her breakfast. she then gets engaged with household works like washing clothes,preparing lunch and she has lunch at 1PM(Rice item),then she takes rest till 5:00PM .In the evenings she usually has tea then she goes for walking from 5:30PM to 6:30 PM and comes home and prepares dinner and has dinner at around 8:00PM along with her family. she usually has Roti  and rice for  her dinner.She goes to sleeps around  9:30 PM.


Personal History:

Diet: Mixed

Appetite:Normal

Sleep: adequate 

Bowel and bladder: regular.

No addictions.


Vitals:

BP:140/90 mm hg

PR: 82 bpm

RR :17 cpm

Temp:afebrile.




PaJR:


https://chat.whatsapp.com/BQKGEjuPKzW5Oh5GVXhIaY


 Thank you







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