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PROBLEMATIC SYMPTOMS IN GENERAL PRACTICE – an appraisal Dr.P.CHITRAMBALAM.M.D .,. “MEDICINE IS AN EVER CHANGING SCIENCE.AS NEW RESEARCH AND CLINICAL EXPERIENCE BROADEN OUR KNOWLEDGE,CHANGES IN TREATMENT AND DRUG THERAPHY ARE REQUIRED.” -HARRISSON -1950.

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problematic symptoms in general practice an appraisal dr p chitrambalam m d

PROBLEMATIC SYMPTOMS IN GENERAL PRACTICE – an appraisalDr.P.CHITRAMBALAM.M.D.,

slide2

“MEDICINE IS AN EVER CHANGING SCIENCE.AS NEW RESEARCH AND CLINICAL EXPERIENCE BROADEN OUR KNOWLEDGE,CHANGES IN TREATMENT AND DRUG THERAPHY ARE REQUIRED.”-HARRISSON -1950

slide3

NO GREATER OPPURTUNITY,RESPONSIBILITY OR OBLIGATION CAN FALL TO THE LOT OF HUMAN BEING THAN TO BECOME A PHYSICIAN

21 st century physician
21ST CENTURY PHYSICIAN
  • ERA OF GENOMICS
  • GLOBALIZATION OF MEDICINE
  • MEDICINE ON THE INTERNET
  • PUBLIC EXPECTATIONS AND ACCOUNTABILITY
  • MEDICAL ETHICS
  • THE PHYSICIAN AS A PERPETUAL STUDENT----

(learning / research / teaching)

slide5

TODAY’S PHYSICIAN STRUGGLES TO INTERGRATE COPIOUS AMOUNTS OF SCIENTIFIC KNOWLEDGE INTO EVERYDAY PRACTICE ----------

  • BUT --------
  • THE INTIMATE RELATIONSHIP BETWEEN THE PHYSICIAN AND PATIENT STILL LIES AT THE HEART OF SUCCESFUL PATIENT CARE-------
  • FOR
  • “THE SECRET OF CARE OF THE PATIENT IS IN CARING FOR THE PATIENT”
when does a symptom become problematic
WHEN DOES A SYMPTOM BECOME PROBLEMATIC ?
  • WHEN IT IS CHRONIC.
  • WHEN IT COMPROMISES DAY TO DAY ACTIVITIES.
  • WHEN IT IS ASSOCIATED WITH HEMODYNAMIC,RESPIRATORY,RENAL OR NEUROLOGICAL DYSFUNCTION.
  • WHEN WE LOOSE HOPE
complaints
complaints
  • Mrs. K aged 25 yrs, from Tiruvannamalai
  • Fever for 4 days
  • Leg swelling for 4 days
history
history
  • H/o vague non specific diffuse abdominal pain
  • H/o dry cough
  • No h/o sore throat
  • No h/o rhinorrhea
  • No h/o breathlessness
  • No h/o diarrhea
  • No h/o joint pain
history1
history
  • Fever
    • 4 days duration
    • High grade ,intermittent
    • Associated with rigors/ chills
    • with headache, generalized body pain
  • No h/o any skin rash
  • H/o swelling of both legs
  • H/o reduced urine output
  • No h/o dysuria / hematuria
history2
HIstory
  • Patient was treated earlier in vellore government hospital. As she was not responding to treatment she came here
  • Not a known DM / SHT / PTB / BA
  • Her menstrual cycles were regular
  • No significant family history
examination
examination
  • Moderately built
  • Febrile (T – 102° F) , Toxic looking
  • Pallor
  • B/L pitting pedal edema
  • B/L inguinal lymphadenopathy
  • Linear ulcer seen over the left inguinal swelling
  • Pulse : 108/min, BP : 110/70 mm Hg
examination1
examination
  • ABD: Soft
  • Liver palpable 4 cm below right costal margin, firm non tender and smooth surface
  • Spleen palpable 3 cm below the left costal margin, soft in consistency
  • CVS : S1 S2 heard, no murmurs
  • RS : B/L NVBS heard, no added sounds
  • CNS : No focal deficits / meningeal signs
clinical diagnosis
Clinical diagnosis

FEVER FOR EVALUATION

? Malaria

? Leptospirosis

? Lymphogranulomavenerum

investigations
investigations

COMPLETE BLOOD COUNT

RFT / LFT

  • TB 1.6 mg / dL
  • DB 1.1 mg /dL
  • AST 60 U
  • ALT 58 U
  • TP 6.4 g /dL
  • Albumin 3.8 g / dL
  • Urea 80 mg / dL
  • Creatinine 1.8 mg /dL
  • Electrolytes - Normal
  • TC 7900 / µL
  • P 69%, L 27%, E 4%,
  • ESR 18 mm / hr
  • Hb 10.1 g / dL
  • Plat 82,000 cells/ µL
  • Smear MP-Neg
  • Dengue -Neg
ultrasound
ULTRASOUND
  • Hepatosplenomegaly
  • Minimal ascites
  • Normal sized kidneys
treatment
treatment
  • IV Fluids, adequate hydration, tepid sponging
  • Inj. Crystalline Penicillin 15 lakhs unit iv qid
  • Tab. Chloroquine
  • Tab. Paracetamol 500mg sos
day 2
Day 2
  • Patient not improved
  • Persistent spikes of fever
  • So repeat head to foot examination was done[ patient was motivated and examined as she was feeling shy]
  • Small blackish discolored lesion on the lateral aspect of the left thigh just near the inguinal fold was found
diagnosis
DIAGNOSIS

ESCHAR - RICKETTSIAL INFECTION

course
course
  • Serological investigations
  • Skin scrapings
  • Patient started on oral Doxycycline 100mg BD
  • Patient had a complete recovery in 3 days and was well at the time of discharge with recovery of the urine output
message
MESSAGE
  • Fever with rash is a common presentation.
  • Patients presenting with inguinal lymph adenopathy and eschar made us suspect scrub typhus.
  • Any patient not responding to conventional management should be re-evaluated by thorough head to foot examination everyday.
  • Orientation towards emerging tropical diseases helps to identify sporadic cases which may be the warning signal of impending epidemic .
fatigue
FATIGUE……..
  • INABILITY TO SUSTAIN THE PERFORMANCE OF AN ACITIVITY THAT SHOULD BE NORMAL FOR A PERSON OF THE SAME AGE,SEX AND SIZE.
  • MOST COMMONLY REPORTED SYMPTOMS
  • MULTIPLE CAUSES
  • MENTAL /PHYSICAL.
history3
HISTORY
  • Mrs.Alamelu,
  • 35 years old female, not educated,
  • Home maker.
  • Presented with the chief complaints of
  • Easy fatiguability x 1 month,
  • More for the past 2 weeks.
  • HISTORY OF PRESENT ILLNESS:
  • She was fairly normal till a month back then she noticed easy fatiguability
  • She could do her normal physical activities but with difficulty in the form of taking prolonged rest in between.
continued
continued
  • H/o associated exertional breathlessness+.
  • H/o exertional palpitation+.
  • H/o exertional chest pain+.
  • H/o light headedness+.
  • H/o excessive sleepiness+.
  • H/o constipation+.
  • H/o amenorrhoea+.
  • H/o dryness of skin +.
  • H/o intolerance to cold+.
  • H/o occasional headache +.
slide28

No h/o bleeding manifestations.

  • No h/o passage of worms in stools.
  • No h/o swelling of legs .
  • No h/o decreased urine output.
  • No history of loss of weight.
  • No h/o appetite loss.
past history
Past history
  • Not a known DM,SHT/BA/CVA/CAD/EPILEPSY.
  • FAMILY HISTORY:
  • No h/o similar illness in the family members.
  • TREATMENT H/O
  • H/o fever 2 weeks back,
  • Evaluated outside,
  • Diagnosed to have sputum –negative PTB and patient got registered under DOTS but not started on ATT.
  • Patient was suspected to have low thyroid hormone level and was referred to GH.
menstrual and obstetric history
Menstrual and obstetric history
  • Menarche -14 years of age .
  • Normal 3/30 days cycle till her 1st pregnancy.
  • Parity -1 ,live -1, son aged 14 years .
  • h/o postpartum hemorrhage.
  • Hospitalized for a week .
  • Transfused 2 units of blood and iv fluids( many pints).

.

continued1
continued
  • Approached a health care facility for amenorrhoea 1 year later
  • Was prescribed some medications after that she developed bleeding per vagina stopped medications then .
  • Found to have decreased thyroid hormone and took treatment for 1 year and stopped.
marital sexual history
Marital & sexual history
  • Married for the past 17 years .
  • One son aged 14 years .
  • SEXUAL HISTORY:
  • h/o decreased libido + .
  • Not interested in having another child.
  • PERSONAL HISTORY:
  • Mixed diet.
  • h/o straining at stools +.
  • No h/o polyuria.
  • No h/o addictions.
summary
summary
  • 35 years old female presented with the history of
  • Easy fatiguability x 1 month.
  • Exertional symptoms .
  • Hypothyroid symptoms .
  • H/o Postpartum hemorrhage.
  • Postpartum lactational failure.
  • Amenorrhoea – 14 years.
  • Decreased libido.
  • symptoms aggravated by fever 2 weeks back.
history in favour of
HISTORY in FAVOUR of
  • ANEMIA.
  • HYPOPITUITARISM.
general examination
General examination
  • Patient – conscious, oriented.
  • Moderately built and nourished.
  • Height -143cms.
  • Weight 41kgs.
  • Anemic.
  • Not jaundiced, no cyanosis, no pedal edema, no clubbing, no significant generalised lymphadenopathy.
  • Dry skin+, no goiter.
slide36

Pulse rate- 80/min, regular.

  • BLOOD PRESSURE:100/80 mmHg left UL sitting posture. JVP not elevated.
  • Temperature: 98 degree Fahrenheit.
  • Not dyspnoeic and not tachypneoic.
  • SPARSE AXILLARY HAIR and PUBIC HAIR.
  • BREAST ATROPHIED.
systemic examination
Systemic examination
  • CARDIOVASCULAR SYSTEM:s1,s2 well heard ,ESM heard over the pulmonary and aortic areas, cervical venous hum+.
  • RESPIRATORY SYSTEM :NVBS heard, No added sounds.
  • ABDOMEN: soft, no organomegaly.
  • NERVOUS SYSTEM:
  • Optic fundus - normal.
  • delayed relaxation of ankle jerk+
investigations2
Investigations
  • HEMATOLOGY opinion:
  • TC:7800cells/cu.mm, P60 L38 E 2.
  • Hb:6.2gms/dl.
  • ESR:68mm/hr.
  • PLATELETS:2 lakh cells/cu.mm.
  • Peripheral smear:

normocytic/hypochromic/macrocytes+.

  • Target cells+.
  • Platelets adequate,clumps+.
slide45

DCT-negative.

  • Reticulocyte count : 0.8%.
contd
Contd...
  • USG ABDOMEN &pelvis:
  • Uterus :4.7 x 2.2 x 1.9 cms.
  • Uterus atrophic.
  • ECHOCARDIOGRAM:
  • Normal study(no evidence of pericardial effusion).
hormonal assays
Hormonal assays
  • FREE T3: 0.57 pg/ml.(2.3 – 4.2)
  • FREE T4: 0.12 ng/dl. (0.8 -2.5 )
  • TSH: 8.36mIU/ml. (1.0-9.1)
  • Inappropriately low for DECREASED FT3,FT4
  • Secondary hypothyroidism.
cortisol
cortisol
  • CORTISOL(a.m) -0.930 microgram/dl.(6.2-19.4)
  • ACTH- 29.38 pg/ml. (7.2-63.3)
  • Serum FSH: 10.2 mIU/ml.
  • Follicular phase (2.5-10.2)
  • midcycle peak(3.4-33.4)
  • Luteal phase(1.5-9.1)
  • Postmenopausal(23.0-116.3) .
slide49

Serum LH: 2.5mIU/ml.(follicular-1.9-12.5)

  • Midcycle peak (8.7-76.3)
  • Luteal phase:(0.5-16.9)
  • Postmenopausal:(15.9-54.0)
contd1
contd...
  • SERUM PROLACTIN: 0.4 ng/ml.
  • Normally menstruating (2.8-29.2)
  • Pregnant(9.7-208.5)
  • postmenopausal(1.8-20.3).
  • GROWTH HORMONE: <0.05ng/ml.(upto 8 ng/ml.)
mri brain
MRI BRAIN
  • Pituitary gland not visualised.
  • Empty sella.
  • Very small posterior pituitary bright spot seen.
  • Infundibulum appears normal.
diagnosis1
Diagnosis
  • SHEEHAN’S syndrome.
treatment in our patient
Treatment in our patient
  • 3units of PRBCS.
  • Inj.vitamin B12 2cc im.od x15 days.
  • T.ferrous sulphate/folic acid 1-0-1.
  • T.calciumlactate 300mg 1-1-1.
  • T.Eltroxin 100 microgram per oral once daily.
  • Inj.25%dextrose tds.
  • Inj.hydrocortisone 50 mg three times a day – 5 days.
  • T.prednisolone 5mg once daily morning.
  • Conjugated estrogen (0.65 mg qd for 25 days)
  • Progesterone (5 mg qd) on days 16–25.
message1
MESSAGE
  • DETAILED CLINICAL HISTORY
  • ARRANGEMENTOF SYMTOMS IN CHRONOLIGAL ORDER
  • ARRIVE AT A SINGLE DIAGNOSIS
  • ENDOCRINE DYSFUNCTION CAN MASK OR MIMIC ANY DISEASE—INCLUDE IT IN YOUR CLINICAL SYSTEM EXAMINATION-CVS,RS,ABD,CNS & ENDOCRINE SYSTEM
chest pain
CHEST PAIN…..
  • MRS.M. 25YRS/F
  • CHEST PAIN – RETROSTERNAL,BURNING IN NATURE PRESENT FOR 3MONTHS.
  • PAIN IS CONTINUOS,NOT RELEATED TO EXERTION OR FOOD BUT INCREASED ON DEEP INSIPRATION.
  • NO FEVER,COUGH 0R WHEEZE
  • HAD ANTIBIOTICS, ANTACIDS,H2 BLOCKERS,PPI FROM
  • VARIOUS PLACES –NO RELIEF.
  • ECG, CHEST X-RAY ECHO, BLOOD INVESTGATIONS AND UGI ENDOSCOPY DONE EARLIER WAS NORMAL
  • PATIENT WAS REASSURED AND ATTENDER WAS BRIEFED FOR THE NECESSITY OF PSYCHIATRIC CONSULTATION.
patient reported to us on26 12 2012
PATIENT REPORTED TO US-on26.12.2012
  • CONCIOOUS
  • ORIENTED
  • NOT ANAEMIC,NOCYANOSIS,NO CLUBBING.
  • NOT JAUNDICED, NO LYMPHADENOPATHY
  • CVS-NAD
  • RS---NAD---EXCEPT FOR MILD TENDERNESS IN RIGHT THIRD COSTAL CARTILAGE
  • ABD-NAD
  • CNS-NAD
  • X-RAY CHEST WAS REPEATED
multislice ct chest
MULTISLICE CT –CHEST.
  • IRREGULAR MASS LESION IS VISUALIZED IN PERIHILAR REGION OF RIGHT LUNG.
  • THE MASS MEASURES ABOUT 6.5 X 5.5CMS.
  • THE MASS ENCASES RIGHT HILAR STRUCTURES.
  • RIGHT HILAR LYMPHADENOPATHY

BRONCHOGENIC CARCINOMA WITH LYMPHNODE METASTASES.

message2
MESSAGE
  • RETROSTERNAL CHEST PAIN IS A COMMON SYMPTOM—CAD/GERD/APD
  • DO NOT FORGET OTHER STRUCTURES BEHIND THE STERNUM—MEDIASTINUM,AIRWAYS,HILAR STRUCTURES & VERTEBRA
  • REFERAL FOR A PSYCHIATRIC CONSULTATION SHOULD BE PLANNED ONLY AFTER EXCLUDING ORGANIC PROBLEMS.
  • SEARCH FOR A DIAGNOSTIC CLUE.
slide69

Mrs.Pounthai, Age 40 Years was admitted with....

  • H/o Distention of abdomen Six Months Duration.
  • Slow onset, Progressive.
  • H/o Malena (+)Transient.
  • H/o Pain abdomen - Six Months back.
  • Said to have had a mass advised surgery.
  • Patient refused - details not available.
slide70

No Pain / Fever / Diarrhoea / Vomiting.

  • No H/o similar illness in the past.
  • No H/o Jaundice / Previous Surgery / Blood Transfusion.
  • Family History / Personal History - Normal.
  • Menstural History - attained Menopause 6 Months back - LCB - 14 Years.
slide71

Patient Concious.

  • Oriented.
  • Comfortable.
  • Not anaemic.
  • Not Jaundiced,
  • No Lymphadinopathy
  • No Cyanosis
  • No Clubbing
  • No external markers of

Hepato Cellular failure

  • CVS
  • RS Normal
  • CNS
examinations of abdomen
Examinations of Abdomen
  • Distended - uniformly
  • Flanks are full
  • Moves with respiration
  • No warmth/Non tender
  • No Organomegaly
  • Shifting dullness (+)
  • Fluid thrill (+)
with a provisional diagnosis of ascites for evaluation the following investigations were done
With a provisional diagnosis of Ascites for evaluation, the following investigations were done.
  • Routine Investigations :-
  • Total WBC Count - 8,000 cells/cumm
  • Differential Count:-
  • Polymorphs : 60 %
  • Monocytes : 32 %
  • Eosinophils : 08 %
  • Haemoglobin : 10.8 mgms %
  • Sugar
  • Urea Normal
  • Creatinine
  • ECG / CXR : Normal
  • HIV : Non-Reactive
  • Echo : Normal Study
slide75

USG abd : Massive Ascitis.

  • ? Cirrhosis of Liver.
  • Pelvic organs

Could not be

Visulaized.

  • Diagnostic Tap :

Faeculent Fluid Drained.

  • Specimen :

Yellow in Colour,

Turbid

  • No Faecalodour
  • Not Blood Stained.
specimen sent for
Specimen Sent for...
  • Smear Study :

No Bacteria,

Occassional Pus cells

with lots Cholesterol

Crystals seen

? Protozoa.

  • Cell Count :

850 Cells

Majority of them are Lymphocytes.

bio chemical analysis
Bio-Chemical Analysis :

Total Protein : 6.2 gms %

Sugar : 32 mgs %

Cl- : 600 mgs %

Globulin : Positive

Total Cholestrol : 568 mgs %

Triglycerides : 216 mgs %

Culture - No growth in Culture.

ct abdomen
CT Abdomen :
  • Massive Ascites.
  • Internal organs normal
  • ? Cirrhosis Liver with PHT.
  • ? TB abdomen.
slide80

Surgeon’s Opinion:

Adviced tube Drainage

  • Gynac.Opinion :

Prolapse Uterus,

No Adnexal Mass.

slide81

Tube Drainage done

about 8 Litres of

Yellow colour Fluid Drained.

  • Peritoneal Biopsy done
  • No Procedural Complications.
  • After Drainage abd. Palpated

? Palpable Transverse Colon

slide82

Repeat USG abdomen - after Drainage.

  • Multiple loculated, Echogenic Fluid Collections with Cystic lesions seen in POD, Subphrenic Space, lesser sac and left para Colic Gutters.
  • Adv-Repeat C.T.Abdomen.
peritoneal biopsy shows
Peritoneal Biopsy Shows...
  • Fibrocollaginous tissue showing

granulation tissue with inflammatory cells.

  • Multinucleated giant cells and pigment

laden macrophages.

  • Areas of haemorrage seen.
  • No evidence of malignancy.
slide85

Patient improved well.

  • Tube blocked-no drainage for 48 hours -removed
  • GAVE US THE ANSWER – Multiple

cysts seen clogged in the tube

HYDATID CYSTS

slide87

ASCITES

  • Multiple cysts
  • Yellow colour fluid.
  • No systemic manifestations
  • Abdominal organs – normal.
  • Other Systems normal.

PERITONEAL HYDATIDOSIS – Probably ‘ PRIMARY’

message3
MESSAGE
  • UNCOMMON PRESENTATIONS SHOULD NOT DISCOURAGE US.
  • MOTIVATION OF COLLEAGUES HELPS TO SOLVE THE ISSUES.
  • CORRECT DIAGNOSIS AND TREATMENT IS ALWAYS REWARDING.
  • HYDATIDOSIS IS COMMON IN MADURAI AND ADJACENT DISTRICTS-HENCE KNOWLEDGE ABOUT REGIONAL DISEASES IS IMPORTANT.
approach
APPROACH………
  • HISTORY IN DETAIL
  • CAREFUL AND INQUISITIVE CLINICAL EXAMINATION-HEAD TO FOOT
  • DIAGNOSTIC INVESTIGATION
slide91

FIRST VISIT-----ALGORHYTHMIC APPROACH.

  • SECOND VISIT---DETAILED HEAD TO FOOT EXAMINATION.
  • THINK TWICE BEFORE DISPOSING THE PATIENT
  • THIRD VISIT--INVOLVE CONSULTANTS,DISCUSS WITH THEM AND BROWSE FOR INFORMATION.
  • REMEMBER TROPICAL DISEASES AND REGIONAL VARIATIONS
  • EVIDENCE BASED CONCLUSION.
  • PRACTICE GUIDELINES.
  • OBSEVATIONAL STUDIES.

.

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