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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