4)Case based OSCE along with BLOOM’S learning levels Achieved
It all started when I was asked to send for the investigations of a 35 year old female who was taken over from the department of Dermatoloy on my OP day. I reluctantly went up as I was already on a roll with the 36hr shifts I had to take. But then as I went to the patient I was filled with compassion for that Thin and undernourished patient who was going through a lot!!
A 35 year old female presented with C/o painful skin lesions over arms, legs, back since 2 months
-C/o Fever and Burning Micturition since 4 days
HOPI-
Patient was apparently asymptomatic 2 months back then she developed painful skin lesions over arms, legs, back. The lesions were sudden in onset, gradually progressive, with no aggravating and relieving factors.
H/o vesicles associated with pus discharge +
H/o fever since 4 days, not associated with chills and rigors, no diurnal variation, relieves with medication.
H/o burning micturition since 4 days. No increased frequency/urgency/hesitancy/decreased Urine output
No C/o SOB/Palpitations/Orthopnea/PND
Past History
The patient has H/o deformities of toes and fingers16 years back
No known comorbidities
Personal History and Daily Routine
Appetite- Decreased
Diet- Mixed
Sleep- Adequate
Bowel and Bladder- Regular (Associated with Burning Micturition 4 days back)
No Addictions
The Patient is a Daily wage worker. She is a mother to 3 kids.
Before the illness she used to wake up around 6am in the morning, and then she gets engaged with household works. She has her breakfast around 8am and then goes for work. She has her lunch at 1pm and then continues her work. She comes home by 6 pm in the evening, has her dinner around 8pm and goes to sleep by 10pm.
General Examination
Patient is Conscious, Coherent, Cooperative
Pallor+
No signs of Icterus, Cyanosis, Clubbing, Lymphadenopathy, Pedal Edema
Vitals:-
Temp- Afebrile
PR-120bpm
RR-18cpm
BP-70/60 mmhg
Systemic Examination
CVS: S1S2 +,
No murmurs
RS: B/LAE +, NVBS
P/A: Soft,NT
CNS: NFND
O/E of skin multiple poly sized ulcers noted over B/L hands, elbows, lower limbs, dorsum of foot
Clinical Images
Investigations:
-Haemogram
Hb- 4.5
TLC- 2500
RBC-2.17
PLT- 4.10
-CRP : Positive
-CUE
Alb- +
Sugars- Nil
Pus cells- Plenty
RBC- 20-25 cells/HPF
-RFT
Urea-37
S.Creat-1.1
S.Na- 137
S.K- 3.3
S.Cl -97
-RA Factor : Positive
Inference
The Inference is that
Leukocytes +++
Nitrites : Positive
Urobilinogen : Normal
Proteins : ++
pH around : 6.5
Blood in urine : ? Hemolysed trace
Sp Gravity : 1.030
Negative for ketones, Bilirubin and glucose in Urine
TREATMENT
1. Tab. Nitrofurantoin 100mg PO/BD
2. Tab. Pantop 40 mg PO/OD
3. Tab. PCM 650mg PO/SOS
4. Syp Potchlor ml in 1 glass of water PO/TID
5. Fudic cream LA/BO
6. Inj. KCl 1 Amp in 500 ml NS over 4-6 hrs IV/STAT
7. Tab. Orofer XT PO/OD
8. Tab. Limcee PO/OD
One Transfusion of FFP was done.
Levels of Blooms:
Level 1:Remembering
It’s all about recollecting and remembering the history of the patient.
Patient was apparently asymptomatic 2 months back then she developed painful skin lesions over arms, legs, back. The lesions were sudden in onset, gradually progressive, with no aggravating and relieving factors.
H/o vesicles
H/o pus discharge
H/o fever since 4 days, not associated with chills and rigors, no diurnal variation, relieves with medication.
H/o burning micturition since 4 days. No increased frequency/urgency/hesitancy/decreased Urine output
Past History
The patient has H/o deformities of toes and fingers16 years back
N/k/c/o DM, HTN, Epilepsy, Asthma, TB
Further adding to the Patient's history-
A small note on the psychological aspects of the patient.
I find the woman to be brave. Despite all the odds (deformities in her toes and fingers) she was still continuing her work. And she was providing for her family which shows that she is responsible, which fascinated me. But looking into her personal history the patient was depressed and had an inferior feeling due to her chronic illness. And these psychological aspects and stressors would’ve contributed to her illness further.
Level 2:
Understanding:
It is all about understanding the disease pattern , it’s pathology and its associations.
Pyoderma Gangrenosum is very much associated with systemic disorders like Rheumatoid Arthritis.
Level 3:
Application:
It is applying the level 1 and 2 knowledge so as to provide a holistic approach of treatment to the patient.
Further investigations can be done so as to know the cause of Anaemia
Serum ferritin was done
Due to lack of resources marrow iron stains couldn’t be done as it would have been more specific.
Level 4:
Analysis:
How sensitive and specific is RF in detecting RA?
RF testing in RA patientsv has a sensitivity of 60% to 90% and a specificity of 85%.
What is the role of RF in RA?
What are the various associations of Pyoderma Gangrenosum?Pyoderma gangrenosum (PG) is associated with systemic disease, mostly rheumatoid arthritis (RA) and inflammatory bowel disease (IBD), in many patients (more than 50%).
Level 5
Evaluation
List of problems-
-Anemia
-Pyoderma Gangrenosum
-Rheumatoid Arthritis
OPD Case:
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