Osce 2 (posted from October 23 to November 23)

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 Osce 2.

Case profile:

Cheif complaints:

Pt presented with c/o itchy skin lesions all over the body since 3 months

History of presenting illness:

Pt was apparently asymptomatic normal 3 months ago later developed itchy skin lesions all over the body

H/o fever since 3 days low grade intermittent relieved with medication 

H/o unknown inj taken 3 months back

H/o facial puffiness since 2 months

H/o Omnacortel 10 mg tab taken for 1 month

And b/l pedal edema since 3 days pitting type 

C/o of stool stools (8 episodes watery non blood stained non mucopurulent) 

Past History-

No h/o similar complaints in past 

No known co morbidities

H/o usage of Etodolac macbestin 500


ENT referal was done i/v/o rt ear pain associated with headache and diagnosed as right otitis externa 

O/E-






Pt is c/c/c 

No pallor cyanosis icterus clubbing lymphadenopathy 

Fever - 99.3F

Bp - 100/70 mmhg

Pr - 120 bpm

Rr- 21cpm

Spo2-99RA

CVS - S1 S2 +

RS - NVBS

CNS - NFND

PA - soft and nt

Skin - 

Multiple erthyematous plaques with scaling noted over chest abdomen b/l forearm arms leg cheeks forehead scalp oral cavity (caries present)

Nails no pitting


Provisional Diagnosis-

Exfoliating Dermatitis 2 to ?drug abuse 

Pyrexia under evaluation with rt otitis externa


INVESTIGATIONS-

C/s-

Skin scarpings KOH Mount-

No fungal elements seen

ESR - 5mm/1st hr

CRP - #1.2 mg/dl (positive)

T3 - 0.84

T4 - 7.54

TSH - 2.91

RBS - 141 mg/dl

TB - 0.60mg/dl

DB - 0.18 mg/dl

AST - 17 IU/l

ALT - 31IU/l

ALP - #196 IU/L

TP - # 5.4 gm/dl

Alb - #3.0

A/G ratio - 1.31

Blood urea - 14 mg/dl

Ser creat - 0.9 mg/dl

Uric Acud - 4.4 mg%

Na - 136

K - #3.3

Cl - 99

Ca - 1.02

Hb - # 11.0

Tlc - #12300

N/l/e/m/b - 66/#15/#10/9/0

Cue - alb and sugars nil

S ca - 8.6mg/dl

Osce questions:

 43F Cushing's, Polyarthritis RA 5 months, exfoliating dermatitis 3 months

43F Cushing's, Polyarthritis RA 5 months, exfoliating dermatitis 3 months Telangana PaJR:  Rakesh Biswas Sir GM Hod Kims: Carpal erosions +

Treat as RA 

Tab Naproxen (check renal function to titrate dose ) 

Tab Prednisolone 10 mg once daily 

Tablet Methotrexate 7.5 mg weekly ( check LFT and CBC for dose titration

Rakesh Biswas Sir GM Hod Kims: This is the cause for her anasarca! 

What's the cause for her hypoalbuminemia? 

24 hour urinary protein and creatinine?

Today's image of the LFT here shows albumin as 2.0! When did it decrease by 1? Very fast? Navyatha  : We are starting 24 hr upcr from tomorrow morning sir

Navyatha : Cue has shown nil proteinuria on both occasions sir

[Rakesh Biswas Sir GM Hod Kims: 

Then more likely to be liver failure (check prothrombin time) or acute inflammatory negative phase reactant(check the rate of serum albumin fall by checking the albumin trends beforw and after admission)?

 Rakesh Biswas Sir GM Hod Kims: 

So came down by 1 in last 10 days! What's the rate of fall of albumin as a negative acute phase reactant in acute inflammatory states?‎[

Navyatha : 

Spot upcr sir

Rakesh Biswas Sir GM Hod Kims: 

By exclusion and association :

The only explanation for her severe hypoalbuminemia is the negative acute phase reaction in response to her current embodied inflammation

‎ Navyatha : 

She is not having any fever spikes or burning micturition and she is using topical fusidic acid for her skin fissures sir do we add any other antibiotic sir derma people were asking about prophylactic antibiotic as pt is started on steroids and open skin surface sir

 Rakesh Biswas Sir GM Hod Kims: 

No antibiotics without any signs of sepsis necessary. 

In fact the tests were unnecessary

 Rakesh Biswas Sir GM Hod Kims: 

Share her case report link in the description box asap

Navyatha : 

Can we treat this as psoriatic arthritis then sir?

 Navyatha : 

Shall we stop low dose prednisolone sir ?

 Rakesh Biswas Sir GM Hod Kims: 

What is the treatment of psoriatic arthritis and it's efficacy. Mention each drug efficacy in a pico format

Rakesh Biswas Sir GM Hod Kims: No continue same and update the response here daily 

Also what do the Dermatologist's say to this report? Did they never suspect psoriasis in her clinically?

https://youtu.be/xvE5b8Xk3vM?feature=shared

Navyatha:

Erythroderma secondary to psoriasis.

C/o chills 

Burning sensation all over the body 

Itching sensation decreased 

Vitals:

Temp: 98.6

Bp: 110/70

PR: 80

Rx:

Tab methotrexate 7.5 mg/once a week

Tab folvite 5mg /Od 

Tab pan 50 mg /od 

Tab shelcal po/od 

Liquid parrafin plus glycerol plus water (1:1:1)

T bact oint L/A B/d 

Protein powder 2tsp in glass water

>] Rakesh Biswas Sir GM Hod Kims:

 75 mg of methotrexate!!! 🧐😨😳👺

[13/10/23, 15:17:24] navyatha : 7.5 mg 


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