Problematic symptoms in general practice an appraisal dr p chitrambalam m d
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PROBLEMATIC SYMPTOMS IN GENERAL PRACTICE – an appraisal Dr.P.CHITRAMBALAM.M.D ., PowerPoint PPT Presentation


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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 .,

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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.,


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


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

  • 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)


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

  • 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


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

  • FEVER


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 .


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

  • FATIGUE


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 +.


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

  • 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.


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

  • 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.


Pallor

PALLOR


Dry skin

Dry skin


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+


Investigations1

INVESTIGATIONS


Renal liver parameters

RENAL &LIVER parameters


Chest x ray

CHEST X-RAY


Ecg low voltage complexes

ECG-low voltage complexes


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+.


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

  • 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) .


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

  • 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.)


Empty sella sign

Empty sella sign


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


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

  • CHEST PAIN


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.


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

  • DISTENSION OF ABDOMEN


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

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.


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

  • 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.


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

  • 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


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

  • 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.


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

Fluid aspiration – Yellow in colour.


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.


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

  • Surgeon’s Opinion:

    Adviced tube Drainage

  • Gynac.Opinion :

    Prolapse Uterus,

    No Adnexal Mass.


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

Tube Drainage done

about 8 Litres of

Yellow colour Fluid Drained.

  • Peritoneal Biopsy done

  • No Procedural Complications.

  • After Drainage abd. Palpated

    ? Palpable Transverse Colon


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

  • 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.


  • Problematic symptoms in general practice an appraisal dr p chitrambalam m d

    USG – abd. – after drainage


    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.


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

    • Patient improved well.

    • Tube blocked-no drainage for 48 hours -removed

    • GAVE US THE ANSWER – Multiple

      cysts seen clogged in the tube

      HYDATID CYSTS


    Hydatid cysts a closer view

    HYDATID CYSTS-a closer view


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

    • ASCITES

    • Multiple cysts

    • Yellow colour fluid.

    • No systemic manifestations

    • Abdominal organs – normal.

    • Other Systems normal.

    PERITONEAL HYDATIDOSIS – Probably ‘ PRIMARY’


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

    She was started on albendazolethen.


    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


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

    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.

      .


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

    WISH THAT NO SYMPTOM BE PROBLAMATIC IN YOUR PRACTICE


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