MD PRACTICAL EXAM
LONG CASE :
34 year old male patient resident of Nalgonda came to the hospital with
CHIEF COMPLAINTS:
Involuntary movements of upper limbs since 4 years
Stiffness of all 4 limbs since 4 years
Slowness of movements since 4 years
Involuntary movements of lower limbs since 3 years
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 4 years back then he developed involuntary movements which developed in right upper limb since 4 years and after 6 months of initiation of right side developed to Left upper limb which was gradual in onset, occurs at rest
since 3 years developed in lower limbs also which were subsided by voluntary movements and also subsides during sleep as told by family members.
Involuntary movements not decreased with levodopa medication.
He has history of difficulty in initiation of movements , to start there is clumsiness of movements and now difficulty to perform his day to day activities like mixing of food , brushing teeth
Difficulty to start walking , able to walk 2 to 3 steps and then stops abruptly for few seconds and then walks fast
He has history of falls once 6 months back
No difficulty in wearing clothes and removing clothes
No difficulty in climbing stairs
No difficulty to wear and remove footwear
No history of slippage of footwear
No history of weakness in upper and lower limbs
No history of giddiness , increased sweating
He has no history of dysphagia , decreased vision, loss of smell
No history of regurgitation.
No history of heart burn.
No history of pooling of saliva.
No history of bowel and bladder involvement
No history of sensory systems
No history of thyromegaly (any neck swelling)
No history of headache
No history of vomiting
No history of siezures
No history of Fever
No history of head injury
No history of jaundice , chronic liver disease
No history of STD
PAST HISTORY
He studied upto 10 th class , after 10th class he started working in chemical factory after 7 months of duration of working in that factory ,during that 7 months he experienced dragging type of pain in lower limbs and decreased sleep then one day while he was working in factory all of sudden he had abnormal behaviour of hitting hands to walls and on TV, visual and auditory hallucinations ( auditory in form of as his father scolding him with abusing words , then he was taken to private hospital diagnosed as ? psychosis started on antipsychotics ( Tab resperidone, tab olanzepine ) since 2006.
No h/o Diabetes, systemic hypertension, bronchial asthma, pulmonary kochs', epilepsy, CVA, CAD, and Thyroid disorder
PERSONAL HISTORY:
Diet: Mixed
Appetite: Normal
Bowl/Bladder:Regular
Sleep: Improved after medication
Addictions: Non smoker and non alcoholic
FAMILY HISTORY:
No significant family history
Drug history : history of intake of antipsychotics since 2006
Currently
Tab levodopa + Tab carbidopa 100/25 mg twice daily
Tab Amantidine 50 mg Truce daily
Tab clonazepam 0.5 mg daily night time
GENERAL EXAMINATION :
Patient conscious, cooperative, Moderately built and moderately nourished
Coarse and static tremor of right and left upper limb ( Right more than left )
GCS 15/15
Height-175cms Weight-65kgs
No pallor, No icterus, no cyanosis, no clubbing , no lymphadenopathy, no edema,no koilonychia
VITALS :
Temp: Afebrile
PR: 85/min regular, normal volume, normal character, no radio radial and no radio femoral delay , Equal on both sides
BP: 100/70mmhg in Left upperlimb on supine
position
On standing 100/60 mmHg in same limb
RR:16/min
SYSTEMIC EXAMINATION:
CENTRAL NERVOUS SYSTEM:
HIGHER MENTAL FUNCTIONS:
Patient is oriented to person place and time
Right Handed person, studied upto 10th standard.
Conscious, oriented to time place and person.
Speech : Stammering type
Memory: recent and remote memory intact
No delusion and hallucinations currently
Emotional lability absent.
MMSE :28 /30
CRANIAL NERVE EXAMINATION:
1st : Normal
2nd : visual acuity is normal
visual field is normal
Normal fundus: fundal glow present.
3rd,4th,6th : pupillary reflexes present.
EOM full range of motion present
5th : sensory intact
motor intact
7th : normal
8th : No abnormality noted.
9th,10th : palatal movements present and equal.
11th,12th : normal.
MOTOR EXAMINATION:
BULK : normal
TONE : Hypertonia in all 4 limbs.
Leadpipe rigidity present in all 4 limbs
Cog wheel rigidity is seen in right more than left
INVOLUNTARY MOVEMENTS:
Resting Tremors present
Describing the involuntary movements:
1. Involuntary movements i.e. tremors observed when patient is unaware
2.Body part affected - all 4 limbs in order ( right upper limb f/by left upper , left lower limb and right lower limb )
3. Frequency of movement - coarse ( High frequency)
4. Amplitude of Movement - low amplitude
5. Timing of movement - predominantly at rest and subsided on voluntary movement
6. Aggravated at rest and relieved on voluntary activity
7. Static tremor.
8. Tremor is more prominent in right upper limb
POWER : U/L L/L
Rt 5/5 5/5
Lt 5/5 5/5
EXAMINATION VIDEOS :
1)https://youtube.com/shorts/g9v34NJ9Qfk?feature=share ( Supraspinatus)
2)https://youtube.com/shorts/m_Pzgs-HlNg?feature=shareh ( Infraspinatus)
3)ttps://youtube.com/shorts/LZ0Nv5Cf0Js?feature=share ( Rhomboid )
4)https://youtube.com/shorts/C7mf7K5rfMg?feature=share ( Deltoid )
5) https://youtube.com/shorts/5CN2NVo7_q0?feature=share ( Lattismus Dorsi )
6) https://youtube.com/shorts/ivZHGxmAg0I?feature=share ( Biceps )
7https://youtube.com/shorts/Z_mP89DMT38?feature=share ( Triceps )
8 ) Brachiradialis
9 ) Stratus Anterior10) Extensor carpu radialis
Extensor digitorum
Extensor carpi ulnaris
Flexor carpi radialis
Adductor pollicisOppenens pollicis
Quadreceps femoris
Tibialis anterior
SUPERFICIAL REFLEXES:
CORNEAL ; LE: present. RE: present
CONJUNCTIVAL : LE: present RE: present
ABDOMINAL : present
PLANTAR : Flexor in both limbs
DEEP TENDON REFLEXES:
BICEPS ++ ++
TRICEPS + +
SUPINATOR + +
KNEE + +
ANKLE + +
Clonus : absent
Glabellar tap : present
SENSORY EXAMINATION:
SPINOTHALAMIC SENSATION:
Crude touch. Normal
pain. Normal
Temperature. Normal
DORSAL COLUMN SENSATION:
Fine touch. NAD
Vibration. NAD
Proprioception. NAD
CORTICAL SENSATION:
Two point discrimination. NAD
Tactile localisation. NAD
stereognosis. NAD
graphasthesia. NAD
CEREBELLAR EXAMINATION:
Normal
No hypotonia and pendular knee jerk : absent
Intention tremor : absent
Rebound phenomenon absent
Nystagmus: absent
Titubation: absent
Rhombergs test : Negative
Dysdidokinesia : Normal
Kneel heel Test
GAIT: Festinating gait
Difficulty in initiation of movements ,
Freezing suddenly
Then started walking with rapid movement
Paucity of automatic movements of both upper limbs ( no swinging movement of arms)
Impaired balance on turning Present
No Micrographia
SIGNS OF MENINGEAL IRRITATION: absent
AUTONOMIC FUNCTION:
No resting tachycardia
No postural hypotension
No excessive sweating
Gait : https://youtube.com/shorts/yO-Ocjp1kz8?feature=share
Other systems examination
CVS:
S1,S2 heard,
no murmurs
RESPIRATORY SYSTEM:
Chest - symmetrical, No paradoxical movements
Normal vesicular breath sounds heard
No abnormal/added sound
ABDOMEN:
Abdomen is soft, non tender.
No organomegaly
No ascites
Bowel sounds+
PROVISIONAL DIAGNOSIS :
Resting tremors, Rigidity with bradykinesia and reduced Arm span with no gaze palsy with no sensory , cognitive, bowel and bladder involvement
Anatomical : Basal ganglion
Pathological : Decrease of dopaminergic levels due to ? Drug induced ( antipsychotics) , unknown chemical induced Parkinson's
Etiology : Drug Induced Parkinson's
ECG :
Investigations:-
CBP:
Hb- 14.5 gm/dl
TLC-8,200/cu. mm
PLT - 2 .8 lakhs/cu. mm
RBS- 81 mg/dl
LFT:
TB -0.71 mg/dl
DB-0.18 mg/dl
AST-15 IU/L
ALT-10 IU/L
ALP- 130 IU/L
TP -6.4 gm/dl
Albumin - 4.53 gm/dl
RFT:
Urea- 24 mg/dl
Creatinine- 1.0 mg/dl
Uric acid- 3.2 mg/dl
Calcium- 9.2 mg/dl
Phosphate- 2.7 mg/dl
Sodium- 145 meq/ L
Potassium- 3.6 meq/L
Chloride- 96 meq/L
CUE:
Colour - pale yellow
Appearance-clear
sp.gravity-1.010
Albumin : +
Sugar -nil
pus cells- 3 to 6
SHORT CASE 1 :
A 40 year old female patient came with complaints of pain in the both hips since 6months
History of present illness :- Patient was apparently alright 6months back,then she developed pain in the both hip regions which is insiduous onset,gradually progressive,aggrevated on walking,getting up from sitting posture,relived on taking medications.
No history of Trauma or fall
Past history
2019: left lower limb weakness and was diagnosed to have hypokalemia for which potassium correction was done
2nd episode: in Nov 2021 had h/o both upper and lower limbs weakness , Loss of consciousness for 2 days , loss of speech (for 4 days) , 1 unit PRBC was transfused and was diagnosed as hypokalemia.
3rd episode : in may 2022 she had same complaints and was admitted for 3 days.
Not a k/c/o HTN, DM,CVA, CAD, EPILEPSY ,TB,ASTHMA, Hepatitis
Personal history:
Diet: mixed
Appetite:normal
Sleep: adequate
Bowel and bladder movements: regular
Addictions:none
Sequence of events:
She got married in 1999 and had her first child in 2002. H/O abortion in 2001.
Due to some issues she worked as a nurse at local hospital for 6 months.
Later her husband passed away in 2009 and in 2010 she got married again. Since then until 2019 she was alright with out any health problems.
1st episode in 2019
2nd episode in 2021
3rd episode in 2022
History of dry eyes , dry mouth and left parotid swelling
General examination:
Pt is conscious, coherent and cooperative
General Condition - Moderately built and Moderately nourished.
Hair - Thin and slightly greyed. Not easily pluckable or no areas of scarring or non-scarring hair loss. No lesions noted on the scalp.
Eyes - No conjunctival chemosis or injection, No redness or corneal lesions.
General Head, Neck & ENT - No abnormalities. No lymph node enlargement.
Axial - No apparent spinal deformities
Fingers and Nails - No clubbing or cyanosis.
Right little finger shows Flexion at the PIP joint
Pt is conscious, coherent and cooperative
No pallor, icterus, cyanosis, clubbing, lymphadenopathy, pedal edema
History of Burning sensation of eyes and Drymouth present
Vitals :
Pr:90bpm , normal volume , no radio radial or radiofrmoral delay
Bp:100/60mmhg , sitting position, left upper limb
Rr:16cpm
Systemic Examination
Musculoskeletal system
Nail changes - No
No alopecia, skin changes
Examination of shoulder joint
*Glenohumeral joint
1. Apprehension tes: Negative
2.Examination of tenderness and swelling over shoulder - No
Examination of Elbow joint
1. Two Thumb technique - No tenderness of wrist
2. prayer sign : Able to do
Examination of MCP joint
sqeeze technique for
Tenderness Examination : Negative
Examination of spine : No tenderness over spine , supraspinatus Muscle
1.patrick test - Negative
2.Garnslen manuoere - Negative
3. Schober's Test - positive
4. Straight Leg raise test - Negative
Glenohumeral joint for Tenderness :
Apprehension Test :
Two Thumb technique:
Squeeze Test for Tenderness of MCP joint : Negative
Tenderness and swelling present over PIP joint of 2nd Phalynx ( right hand )
Flexion of PIP of little finger ( right hand )
Trandelenberg Test : Positive on both sides
Knee joint Palpation : For Tenderness
Ankle joint for Tenderness
Patrick Test :
Gait video :
Schober's test
Cvs:
s1, s2 present
RS: BAE + , clear
CNS: NAD
P/A :
soft , non tender
Bowel sounds:sluggish
PROVISIONAL DIAGNOSIS:
The above features suggestive of connective tissue disorder - sjogrens syndrome ( Dry eye, Dry mouth ,biopsy of labium is positive for sjogrens )
Right hip pain secondary to ? Bone involvement spondyloarthropathy
Hypokalemic periodic paralysis secondary to distal Renal tubular acidosis
Investigations
ECG :
Chest x ray :
X ray B/L wrist
X ray pelvis
RBS - 101mg/dl
CUE
Color - pale yellow
Appearance - clear
Reaction - acidic
Specific gravity -1.01
Albumin - trace
Sugars - nil
Bile salts - nil
Bile pigments - nil
Pus cells : 3-4
Epithelial cells : 2- 3
RBC - nil
Crystals - nil
Casts - nil
RFT
Urea - 16mg/dl
Creatinine - 1.3mg/dl
Uric acid - 3.1 mg/dl
Calcium - 10.1mg/dl
Phosphorus - 2.6mg/dl
Sodium - 141mEq/L
Potassium - 3.6 mEq/L
Chloride - 105 mEq/L
LFT
Total bilirubin - 0.67mg/dl
Direct bilirubin - 0.12mg/dl
SGOT - 14 IU/L
SGPT -11 IU/L
Alkaline phosphatase - 492 IU/L
Total proteins - 6.6 gm/dl
Albumin- 4.02gm/dl
A/G ratio 1.56
ESR - 30mm/ 1st hour
Histopathology report:
H and E stained section shows presence o multiple lobules of minor salivary glands tissue consisting of normal appearing mucinous acini with intralobular and interlobular ducts .
The salivary gland tissue also shows the presence of multiple foci greater than 5 of lymphocytic infiltrate, endothelial lined blood vessels and hemorrhagic areas
Short case 2 :
60 year old male presented to the casualty with complains of altered sensorium since 2 days, generalized weakness since 2 days
60 year old farmer and daily wage labourer by occupation resident of errasanigudam starts his daily routine with waking up at 5 am in the morning and goes to his farm work till 11 am and then have his food and goes back to farm at 12 am and comes back to his home at 6 pm and comes and has his dinner by 7:30 pm
He has no children, first child was born at 8 months of pregnancy and died with in 1 day of birth
His wife conceived 2nd time 5 years after previous pregnancy and the child died at 2 months of age
Patient started drinking toddy from his 22 years of age drinks toddy daily 1 litre
He occasionally drinks alcohol 2 quarters once monthly when he meets his relatives and attends party
His life was routine till the last 4 years
4 years ago he developed fever for 1 week and had some giddiness and fallen from bed hr was then immediately taken to the hospital where he was diagnosed as having high sugars and high blood pressures he was hospitalized for 3 days and came home
Since then he is on antihypertensives and oral hypoglycemic drugs
Patient work life compromised since then he stopped going to work since then and started staying home as he was having generalized body pains and difficulty in bending and doing works
His wife used to go for work and make money for his living and he used to get pension money which he is using for his medications
Patient was doing fine in the last 4 years staying at home and doing his daily household chores
20 days ago patient developed altered behaviour ( started scolding his wife ), generalized weakness patient was taken to local hospital, where he was evaluated and found to have low blood sugars ,deranged renal parameters and was admitted for 3 days
Personal history:
Diet: mixed
Appetite:normal
Sleep: adequate
Bowel and bladder movements: regular
Addictions:none
General examination
Patient is drowsy but arousable
Pallor present, pedal edema present
No icterus ,cyanosis, clubbing, lymphadenopathy,
Vitals
BP - 150/80 mm of hg
PR-75 bpm
Spo2-97 on RA
RR-25 con
TEMP-98.7 F
GRBS-176 mg/dl
Local examination of spine :
Spine tenderness present at sacroiliac joint
No paraspinus muscle tenderness
SLRT : Negative
Gait video :
Systemic Examination
CVS
Inspection : Keloid present over anterior chest
No visible Apex, pulsations, engorged veins
Palpation : Apex beat at 5th ICS 1.5 cms lateral to mid clavicular line
No Parasternal haeve
Ascultation : S1, S2 present
Respiratory system
BAE+,NVBS
Per abdomen
Soft, non tender , umbilical hernia present
CNS : NAD
Provisional Diagnosis : Altered Sensorium secondary to Hypoglycemia ( OHA induced ) / Uremic Encephalopathy secondary to renal failure ( ? CKD )
Anameia secondary to CKD
DM 2 and HTN since 1 year
Heart failure with ? Preserved EF
metabolic syndrome
umbilical hernia
Investigations
Hb- 8.3g/dl
TLC - 15,200cells/cumm
Neutrophils - 83
Lymphocytes - 10
Eosinophils - 01
Monocytes - 06
Basophils -00
Platelet - 2.60L
CUE
Puscells- 6 to 8
Albumin - ++
Specific gravity - 1.010
RBS - 80mg/dl
RFT
Blood urea -124
Serum creatinine - 7.1
Sodium -140
Potassium- 3.7
Chloride - 98
Calcium ionised - 9.1
LFT
Total bilirubin - 0.64
Direct bilirubin - 0.19
SGOT - 37
SGPT -30
ALP-374
Total protein - 5.8
Albumin -3.1
A/G ratio- 1.13
ECG :
Xray
Xray dorsolumbar spine
2DEcho
RA, LA , LV Dilated
EF : 60 %
Good systolic function
Diastolic Dysfunction +
Mild MR, AR
Moderate TR with PAH
IVC collapsing (1.33 cms )
1)Efficacy and Safety of Deep Brain Stimulation in the Treatment of Parkinson’s Disease: A Systematic Review and Meta-analysis of Randomized Controlled Trials
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6318091/
P: Double blinded study
8 RCT were done among which 2 included early Parkinsons disease patients
I:
Deep brain stimulation
DBS of any kind (i.e., unilateral or bilateral; any target area) was compared to BMT.
C:
Between Deep brain stimulation and the medical management.
O:
Outcome measures were impairment/disability using the Unified Parkinson’s Disease Rating Scale (UPDRS), quality of life (QoL) using the Parkinson's Disease Questionnaire (PDQ-39), levodopa equivalent dose (LED) reduction, and rates of serious adverse events (SAE).
There was a significantly greater reduction of Levodopa equivalent dose in patients with early PD (P < 0.00001), but no other differences between early and advanced PD patients were found.
DBS was superior to Best medical therapy at improving impairment/disability, Quality of life and reducing medication doses.
2)Efficacy and safety of topical and systemic medications: a systematic literature review informing the EULAR recommendations for the management of Sjögren’s syndrome
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6827762/
P: Double blinded study
120 patients of primary sjogrens were taken were taken for randomised control trial
I:
Oral Hydroxychloroquine vs placebo
C:
Compared between 56 ppl who has taken 400mg/day of hydroxychloroquine and 64 ppl taken as placebo.
O:
Primary Outcomes measured in terms of VAS scores (dryness,fatigue,pain) at 24weeks
30% reduction of 2 symptoms at 24 weeks (among both groups,with no statistical significance)
one of the secondary outcomes, hydroxychloroquine was associated with a statistical trend to improved pain (p values between 0.06 and 0.10 at 12, 24 and 48 weeks) although it was not superior to Placebo for articular involvement.
No statistical differences were found in response to fatigue.
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