General Medicine Internship OSCEs Towards Optimizing Clinical Complexity

 This online E-log Entry Blog is an objectively structured clinical examination method to assess the clinical competence during the course of my General Medicine Internship rotation (october'2023-november'2023) by reviewing the case reports shared below and to discuss, understand and review the clinical scenarios and data analysis of patients so as to develop my clinical competency in comprehending clinical cases, and providing evidence-based inputs for questions surrounding the clinical vignettes borrowed from the E Log Book.

Note: The cases have been shared after taking consent from the patient/guardian. All names and other identifiers have been removed to secure and respect the privacy of the patient and the family

CASE SCENARIO:

A 65 year old female, resident of west bengal and belonging to middle class according to modified kuppuswamy scale presented to the general medicine OPD with chief complaints of:

-continuous dribbling of urine since the past 4 years

- constipation since past 3 years.

- shortness of breath since 3 years. 

Patient was apparently asymptomatic 26 years ago , when she developed:

* continuous dull aching pain in both the knee joints, which was exaggerated in the mornings and was bearable throughout the day, it was aggravated on walking and relieved on rest, associated with redness around the knees

- N/H/O trauma

- N/H/O fever with evening rise of temperature, cosmetic deformity(varicosity, skin discoloration)

- later as the disease progressed she underwent bilateral knee replacement surgery in the year 2015.

* continuous dribbling of urine since 4 years, which was insidious in onset with a few drops during the day and gradually progressed to continue throughout the day and wetting of bed during the night, urine is yellow in color with ammonical odour. Aggravated on consumption of coffee & drinking more than 1.5 lit of water.

* patient reports recurrent UTIs where in she complains of 

-burning micturition

-pain before and while micturition

-no history of hematuria, frothy urine

* patient also reports constipation since 3 years,

- she passes 1 bowel movement per 2-3 days , associated with pain 

- patient passes flatus

- not associated with blood, abdominal distention, weight loss 

* fever since 1 day, sudden onset, high grade, continuous, no aggravating and relieving factors, associated with bodyache, headache.

https://pallikhyathi113.blogspot.com/2023/10/a-63yr-old-female-with-rheumatoid.html 

Questions : 

General approach to the patient: 

1.List all the complaints of the patient with respect to the history and relevant clinical data and mention the treatment plan for each listed problem and mention treatment plan stating it's efficacy in relevance to patient relief and better outcome. 

Answer: 

C/o continuous dribbling of urine since past 4 yrs 

C/o constipation since 3 years 

H/O rheumatoid arthritis since past 26yrs, is on regular medication. 

 H/O HTN since past 20yrs on regular medication. 

K/c/o DM - 2 

Treatment advised : 

Tab.CLINIDIPINE/TELMASARTAN/CHLORTHALIDONE (10/40/12.5mg) - This is for her hypertension

Tab.METFORMIN 500mg - This is for her Diabetes 

Tab.METHOTREXATE 7.5mg - As she is a known case of RA this is to be continued

Syp.CREMAFFIN PLUS -This is to treat constipation.

For her c/o continuous urine dribbling we have performed uroflowmetry in our hospital 

We asked the patient to sit on this chair and ask her to urinate. There is a funnel through which the urine is collected into the jar below and this is connected to the computer monitor through which we can actually get the flow pressure in the form of a graph . 

2. What was the rationale behind the initial provisional diagnosis of urosepsis and burning micturition? 

Answer- Her blood investigations shows: HAEMOGLOBIN: 10.7 g/dl

TOTAL COUNT : 12,100 cells/comm

NEUTROPHILS: 64% 

LYMPHOCYTES: 11 %

EOSINOPHILS: 01%

MONOCYTES: 04%

BASOPHILS:00%

PLATELET COUNT2.88

SMEAR: Normocytic normochromic blood picture with neutrophilic leucocytosis

COMPLETE URINE EXAMINATION (CUE)

 COLOUR: Pale yellow

APPEARANCE: Cloudy

REACTION: Acidic

SP GRAVITY1.010

ALBUMIN: ++++

SUGAR: NIL 

BILE SALTS: NIL

BILE PIGMENTS : NIL

PUS CELLS: PLENTY

EPITHELIAL CELLS:1-2  

3. On Inspection of the patient, her abdominal visceral fat is prominent. 

What could be the cause for it based on the patient's history? 

Answer- As we look into her personal history , they have restaurant in their area and they sell fried and fast food and mostly they even prefer to eat that food and also foods that include maida , more amount of sugar consumptions this may lead to her diagnosis of DM-2 

We have advised her to strictly follow her Diabetic diet i.e eating healthiest food in moderate amounts and sticking to regular meal times .

Includes: carrots,green leafy vegetables,green peas , fruits like : orange,melon,apples,

Grains like:wheat,barley,millets 

Nonfat/low fat 

After explaining this to patient , they got discharged and patient started uploading her meal in the PaJr group regularly . 

She will have her meal in small intervals i.e around : 

9am----10:20am---11:45am---4:00pm 

 

@9am

@10:20am

 

@11:45am

 

@4pm

                                            

4 .If the patient is in systemic inflammatory response syndrome secondary to infection, what evidence supports this ? 

Answer: Patient have complaints of early morning joint stiffness and pains since 35years and because of this pains she could not walk for long distance and this is one of the reason for her weight gain and lack of physical activity .

 

*USG for bladder size 

Impression: pre void -190ml 

                      Post void-110ml 

Suggestive of Post voidal residual volume is present i.e she is not able to empty her bladder completely.

Urine culture sensitivity done : 

Impression: 6-7/HPF pus cells seen and pseudomonas aeruginosa isolated 

5. How will you explain the condition to the patient and motivate her to decrease weight as she is a diabetic and couldn't do any physical activity? 

Answer: 

Our patient she actually wants to decrease her weight but due to the pains she is having she couldn't do it . 

Firstly , we have advised her to strictly follow her Diabetic diet and to take them in small intervals and completely avoid maida foods . Gradually her weight would decrease and then the weight pressure on her knees would reduce gradually and  there is a chance that she could walk and do some of her physical activities 

Coming to her over active bladder , we have advised her some life style changes like avoid the foods / drinks that irritate bladder like coffee 

Double voiding i.e after she goes to bathroom wait for few seconds and try to void again 

Also explained some exercises for relaxing bladder muscles : KEGEL EXERCISE to strengthen the pelvic floor 

Along with the above life style changes and physical exercises advised the patient to continue her medication regularly as prescribed. 

https://pallikhyathi113.blogspot.com/2023/10/a-43-yr-old-female-came-with-complaints.html 

https://pallikhyathi113.blogspot.com/2023/10/a-32-yr-male-came-with-complaints-of.html 

https://pallikhyathi113.blogspot.com/2023/10/a-40yr-female-came-with-complaints-of.html 

https://pallikhyathi113.blogspot.com/2023/10/60yr-old-female-came-with-complaints-of_15.html 

https://pallikhyathi113.blogspot.com/2023/10/63yr-old-male-complaints-of-fevercough.html