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PROBLEMATIC SYMPTOMS IN GENERAL PRACTICE – an appraisal Dr.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.

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

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

  2. “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

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

  4. 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)

  5. 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”

  6. 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

  7. FEVER

  8. complaints • Mrs. K aged 25 yrs, from Tiruvannamalai • Fever for 4 days • Leg swelling for 4 days

  9. 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

  10. 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

  11. 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

  12. 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

  13. 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

  14. Clinical diagnosis FEVER FOR EVALUATION ? Malaria ? Leptospirosis ? Lymphogranulomavenerum

  15. 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

  16. ULTRASOUND • Hepatosplenomegaly • Minimal ascites • Normal sized kidneys

  17. treatment • IV Fluids, adequate hydration, tepid sponging • Inj. Crystalline Penicillin 15 lakhs unit iv qid • Tab. Chloroquine • Tab. Paracetamol 500mg sos

  18. 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

  19. DIAGNOSIS ESCHAR - RICKETTSIAL INFECTION

  20. 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

  21. 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 .

  22. FATIGUE

  23. 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.

  24. 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.

  25. 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 +.

  26. 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.

  27. 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.

  28. 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). .

  29. 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.

  30. 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.

  31. 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.

  32. HISTORY in FAVOUR of • ANEMIA. • HYPOPITUITARISM.

  33. 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.

  34. 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.

  35. PALLOR

  36. Dry skin

  37. 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+

  38. INVESTIGATIONS

  39. RENAL &LIVER parameters

  40. CHEST X-RAY

  41. ECG-low voltage complexes

  42. 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+.

  43. DCT-negative. • Reticulocyte count : 0.8%.

  44. Contd... • USG ABDOMEN &pelvis: • Uterus :4.7 x 2.2 x 1.9 cms. • Uterus atrophic. • ECHOCARDIOGRAM: • Normal study(no evidence of pericardial effusion).

  45. 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.

  46. 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) .

  47. 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)

  48. 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.)

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