Case Based OSCE Along With Bloom's Learning Levels Achieved

Case Based OSCE Along with Bloom's Learning Levels Achieved

Note - This is an a online e log book to discuss our patient's de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment

 CHIEF COMPLAINTS:

 

The patient presented to the OPD with the chief complaints of -

- Lower abdominal pain since 10 days

- Bilateral pedal edema since 3 years

HOPI:

 

The patient was apparently asymptomatic 10 days ago and then he developed pain in the lower abdomen which is sudden in onset, non radiating, dragging type, no aggravating factors, relieved temporarily on medication.

 

The patient also complains of bilateral pedal edema of pitting type since 3 years which occurs on prolonged sitting and relieved at night on lying down in supine position with legs elevated. The patient also mentions that he urinates 2 to 3 times during the night following which the pedal edema is relieved. This urge to urinate multiple times at night leads to disturbance in his sleep.

 

No h/o SOB, orthopnea, PND, palpitations, giddiness, fever, diarrhea, constipation, lower urinary tract symptoms, discolorations of urine or stools, bleeding manifestations

 

PAST HISTORY:

 

K/c/o Hypertension since 5 years, using Amlodipine 5mg and Atenolol 50mg

Pt complained of pain in right upper abdomen 7 years ago and was diagnosed with Cholelithiasis, underwent Cholecystectomy

N/k/c/o DM, Asthma, TB, Epilepsy, CAD, CVD

 

PERSONAL HISTORY:

The patient wakes up at 5:00am and finishes his morning chores such as brushing, bathing and breakfast. His occupation is animal husbandry and business involving farm animals. His job involves him travelling often on the bike and in the bus during which his pedal edema is exacerbated. He sleeps at around 9:00pm daily. His sleep is disturbed due to urge to urinate multiple times during the night.

 

His diet is mixed, appetite is normal and bowel and bladder movements are regular

 

GENERAL EXAMINATION

 

Patient is conscious, coherent and cooperative and well oriented to time, place and person

He is well-built and nourished

No pallor, icterus, cyanosis, clubbing, lymphadenopathy and pedal edema

 

Vitals on admission -

Temp - Afebrile

BP - 120/80 mm hg

PR - 78bpm

RR- 18cpm

 

SYSTEMIC EXAMINATION:

CVS:  S1, S2 heard , no murmurs

CNS:  NAD

RS:  B/L air entry + , trachea central , NVBS heard

P/A : obese, midline scar present, soft, non tender

Splenomegaly present, spleen palpable 4-5cm below the costochondral margin.

 

PROVISIONAL DIAGNOSIS:

?Tropical Splenomegaly  

 

TREATMENT:

Inj ARTESUNATE 180mg

Inj MULTIVITAMIN 1amp in 100ml NS OD

Tab SHELCAL  PO/OD

 

Bloom's Taxonomy levels:

1. Knowledge (Remembering):

Tropical splenomegaly syndrome, also known as hyperreactive malarial splenomegaly, occurs due immunological overstimulation to repeated attacks of malarial infection over a long period of time.[1] Condition is usually seen in malaria-endemic areas like Africa and Indian subcontinent.[2] Tropical Splenomegaly Syndrome is characterized by massive splenomegaly, hepatomegaly, marked elevations in levels of serum IgM and anti-malarial antibodies. The spleen is massively enlarged. It shows dilated sinusoids lined with reticulum cells. There is a marked erythrophagocytosis and lymphocytic infiltration of the pulp. Peripheral smear for malarial parasite is usually negative.

 

2. Comprehension (Understanding):

GRADING OF SPLENOMEGALY

  SOURCE:- https://images.app.goo.gl/dGDzDfVa6G7qYnas7

 

CRITERIA FOR SPLENOMEGALY

SOURCE :- https://images.app.goo.gl/Ai9Zx2FJvfvRZnvZ9 

 

 

3. Application (Applying):

 Medical Care

Therapy is based on the use of antimalarial drugs. A literature review by Leoni et al indicated that a short therapy course is sufficient treatment for HMS in patients who, after exposure to malaria parasites, do not revisit areas where malaria is endemic. In such patients, according to the study, elimination of the infection effectively cures the splenomegaly. The investigators, who drew data from 89 papers, asserted that patients who continue to be exposed to malaria-endemic regions require intermittent therapy or possibly lifelong treatment. [34]  Addition of doxyxline to the antimalarial may be of benefit; Genderini et al administered dihydroartemisinin/piperaquine (320/40 mg three tablets/day for 3 days) with doxycycline 200 mg to a patient once a day for 6 weeks, with complete resolution of HMS.

 

A retrospective, longitudinal study by Bisoffi et al indicated that patients with early HMS should receive the same treatment as patients with the full-blown syndrome, since early HMS predisposes patients to the more advanced condition. The study found that among patients with early HMS, re-exposure to malaria is a major risk factor for progression and stated that, while a single antimalarial treatment will probably prove adequate against early HMS, antimalarial prophylaxis should subsequently be used in re-exposed patients.

 

Surgical Care

Splenectomy plays no role in the treatment of hyper-reactive malarial splenomegaly (HMS) and should be avoided, as it can result in fulminant and overwhelming infections with high mortality.

 

 

 

SOURCE :- https://emedicine.medscape.com/article/959720-treatment?form=fpf 

 

4. Analysis (Analyzing):

 

l MP STRIP TEST - NEGATIVE

l USG ABDOMEN - POST CHOLECYSTECTOMY STATUS, B/L GRADE 2 RPD CHANGES WITH RENAL CORTICAL CYSTS, GROSS SPLENOMEGALY

l LIVER FUNCTION TEST:- T.B:- 1.45  DB :-0.42 AST:-14 ALT 16ALP:- 104 T.P :- 6.0 ALBUMIN:-4.35 A/G RATIO :- 2.64

l RENAL FUNCTION TEST:- UREA :- 27 CREATININE : 0.9 URIC ACID :- 5.7 CA2+ :- 9.5 PHOSPHORUS:- 2.7        NA+/K+/CL-  : - 136/3.6/101

l COMPLETE URINE EXAMINATION :- NORMAL

l HEMOGRAM

          HB:- 12.2

 TC:-4,700 N/L/E/M/B :- 63/29/02/06/00

PCV/MCV/MCH/ MCHC :- 32.8/79.2/29.5/37.2

RBC COUNT:- 4.14

 

IMPRESSSION:- NORMOCYTIC NORMOCHROMIC BLOOD PICTURE WITH MILDHYPOTHROMBOCYTOPENIA

      

   

5. synthesis (Creating):

SO WE FOLLOWED BELOW TREATMENT PLAN FOR 5 DAYS

l Inj. ARTESUNATE 180mg

l Inj. MULTIVITAMIN 1amp in 100ml NS OD

l Tab SHELCAL  PO/OD

 

6. Evaluation (Evaluating):

WE GAVE  ARTESUNATE 180mg/I.V  for 5 days after which pt. Complaints were relieved and hence was discharged in HEMODYNAMICALLY STABLE CONDITIONS .