General Medicine Internship Real Patient OSCEs towards optimizing clinical complexity

Introduction: This online E-log Entry Blog is an objectively structured clinical examination method to assess the clinical competence during the course of my General Medicine Internship rotation (June'2023-August'2023) by reviewing the case reports shared below and to discuss, understand and review the clinical scenarios and data analysis of patients so as to develop my clinical competency in comprehending clinical cases, and providing evidence-based inputs for questions surrounding the clinical vignettes borrowed from the E Log Book.

Note: The cases have been shared after taking consent from the patient/guardian. All names and other identifiers have been removed to secure and respect the privacy of the patient and the family.

AMC CASE NO.1 

PATIENT CAME TO OPD WITH C/O VOMITINGS SINCE 1WEEK

YELLOWISH DISCOLOURATION Of EYES SINCE 1WEEK

Detailed history::::patient was a AUTODRIVER  by occupation works daily from 7am  to  9pm  developed. VOMITINGS SINCE 1WEEK YELLOWISH DISCOLOURATION Of EYES SINCE 1WEEK PATIENT WAS APPARENTLY ASYMPTOMATIC 1WEEK AGO THEN HE DEVELOPED VOMITINGS 3-4 EPISODES/DAY WITH FOOD MATERIAL AS CONTENT, NON BILIOUS, NON BLOOD TINGED, HISTORY OF ABDOMINAL Pain In EPIGASTRIC REGION 5DAYS AGO, NO H/O DIARRHEA

HISTORY OF HIGH GRADE FEVER 1WEEK Ago ASSOCIATED WITH CHILLS AND Rigor, CONTINOUS TYPE OF FEVER, RELIEVED ON MEDICATION

NO FEVER SINCE 5 DAYS

HISTORY OF MILD ITCHING OVER BOTH THIGH REGION

http://133trajesh.blogspot.com/2023/06/22yr-old-with-viral-pyrexia_15.html

Yellowish discolouration trends

Questions:::::

1Q.what is diagnosis for this case with basis on complaints ????

Ans::: Thrombocytopenia with  AKI ??hepatitis viral/leptosipra 

2Q.Why not dengue thrombocytopenia with dengue hepatitis????

Ans::Since jaundice is relatively uncommon in cases of dengue, patients with jaundice and a dengue-like illness should be considered for early evaluation for both dengue and leptospirosis. Laboratory investigations remain mandatory for confirmation.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8373406/#:~:text=Therefore%2C%20for%20a%20definitive%20diagnosis,centers%20and%20high%2Dend%20laboratories

3Q.What tests can confirm with 100% certainty? Are they available in our hospital?

Ans.Blood samples for polymerase chain reaction (PCR) and serology (immunoglobulin IgM and IgG).

Evidence link::::Screening tests for leptospirosis include IgM based assays (ELISA, immuno-dot and lateral flow) which are cost-effective, easy to perform and available in most of the laboratories. However, their results should be confirmed by confirmatory tests like microscopic agglutination test (MAT) or polymerase chain reaction (PCR).For presumptive diagnosis of dengue infection, IgM capture ELISA is used and can be confirmed with a nucleic acid amplification test https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8373406/#:~:text=Therefore%2C%20for%20a%20definitive%20diagnosis,centers%20and%20high%2Dend%20laboratories.

4Q.What Test was used for your patient?

Ans. HEPATITIS A VIRUS IGM ANTIBODY--2.86 Turned out as positive

Normal values(<0.8 -negative;

>1.2-positive)

HBSAGRAPID-NEGATIVE

HIV1/2RAPID-NON REACTIVE

ANTI HCV ANTIBODIES- Negative

5Q.Based on the patient's history, clinical findings what could be jaundice,Fever spikes in this patient be attributed t?   

Ans..RISE in jaundice could be major injury to liver causing raising Total bilirubin by 

Virus 

Hepatitis A is a viral infection that causes inflammation of the liver. Hepatitis A is very contagious and transmitted through food or water containing the virus.

Hepatitis refers to inflammation of the liver caused by exposure to toxins, alcohol misuse, immune diseases, or infection. Viruses cause the majority of cases of hepatitis, including all cases of hepatitis A.

Hepatitis A is a form of the disease caused by the hepatitis A virus (HAV). This is an acute (short-term) type of hepatitis, which usually requires no treatment.

Approximately 1.5 million casesTrusted Source of hepatitis A occur around the world each year, with annual rates increasingTrusted Source in the United States. This highly contagious form of hepatitis is spread primarily through contaminated food or water. It generally isn’t serious and usually causes no long-term effects. A hepatitis A infection usually goes away on its own.

6Q.What are the symptoms of hepatitis A?

Children under the age of 6 typically show no symptoms when they contract the virus. Older children, teens, and adults usually develop mild symptoms, which can include:

• flu-like symptoms (fever, fatigue, body aches)
• abdominal pain (especially in the right upper quadrant)
• light-colored stool
• dark urine
• loss of appetite
• unexplained weight loss
• jaundice (yellowing of skin or eyes)

Symptoms usually appear 14 to 28 days after you contract the virus.

7Q.What causes hepatitis A and how is it contracted?

People develop a hepatitis A infection after contracting HAV. This virus is typically transmitted by ingesting food or liquid contaminated with fecal matter that contains the virus. Once transmitted, the virus spreads through the bloodstream to the liver, where it causes inflammation and swelling.

In addition to transmission from eating food or drinking water containing HAV, the virus can also be spread by close personal contact with someone who already has it. HAV is contagious, and a person who has hepatitis A can easily pass the disease to others living in the same household.

You can contract hepatitis A by:

• eating food prepared by someone with the hepatitis A virus
• eating food handled by preparers who don’t follow strict hand-washing routines before touching food that you eat
• eating sewage-contaminated raw shellfish
• having sex with someone who has the hepatitis A virus
• drinking polluted water
• coming in contact with hepatitis A-infected fecal matter

If you contract the virus, you’ll be contagious 2 weeks before symptoms even appear. The contagious period ends about 1 week after symptoms appear.

8Q.Is there any way to prevent hepatitis A?

The No. 1 way to avoid getting hepatitis A is by getting the hepatitis A vaccine. This vaccine is given in a series of two injections, 6 to 12 months apart.

If you’re traveling to a country where hepatitis A transmission is more common, get your vaccination at least 2 weeks before traveling. It usually takes 2 weeks after the first injection for your body to start building immunity to hepatitis A. If you’re not traveling for at least a year, it’s best to get both injections before leaving.

Check your destination on the Centers for Disease Control and Prevention (CDC) site to see if you should get a hepatitis A vaccination.

To limit your chance of contracting hepatitis A, you should also:

• thoroughly wash your hands with soap and warm water before eating or drinking, and after using the restroom
• drink bottled water rather than local water in developing countries, or in countries where there’s a high risk of contracting hepatitis A
• dine at established, reputable restaurants, rather than from street vendors
• avoid eating peeled or raw fruit and vegetables in an area with low sanitation or hygienic standards

9Q.Who is at risk of getting hepatitis A?

Hepatitis A is usually spread from person to person, making it highly contagious. But certain factors can increase your risk of contracting it, including:

• living in (or spending an extended time in) an area where hepatitis A is common, including most countries with low sanitation standards or a lack of safe water
• injecting or using illegal drugs
• living in the same household as someone who’s hepatitis A-positive
• having sexual activity with someone who’s hepatitis A-positive (barrier methods don’t adequately prevent the spread of hepatitis A)
• being HIV-positive
• working with non-human primates

The World Health Organization (WHO)Trusted Source reports that more than 90 percent of children living in countries with low sanitation standards will have had a hepatitis A infection by age 10.

In past decades, people with clotting disorders like hemophilia were at higher risk of contracting hepatitis A via transfusion therapy, though these cases are extremely rare today.

10Q.How is hepatitis A diagnosed?

Some people have only a few symptoms and no signs of jaundice. Without visible signs of jaundice, it’s hard to diagnose any form of hepatitis through a physical examination. When symptoms are minimal, hepatitis A can remain undiagnosed.

After you discuss your symptoms with your doctor, they may order a blood test to check for the presence of a viral or bacterial infection. A blood test will reveal the presence (or absence) of the hepatitis A virus.

Complications due to a lack of diagnosis are rare.

11Q.How is hepatitis A treated?

There’s no formal cure for hepatitis A. Because it’s a short-term viral infection that goes away on its own, treatment is typically focused on reducing your symptoms.

After a few weeks of rest, the symptoms of hepatitis A usually begin to improve. To ease your symptoms, you should:

• avoid alcohol
• maintain a balanced diet
• drink plenty of water
• limit the use of over-the-counter medications 

12Q.What is the long-term outlook after contracting hepatitis A?

With rest, your body will most likely recover completely from hepatitis A in a matter of weeks or a few months. Usually, there are no negative long-term consequences of having the virus.

In extremely rare cases, hepatitis A can lead to acute liver failure. This complication is most common in older adults and people who already have chronic liver disease. If this occurs, you’ll be hospitalized. Even in cases of liver failure, a full recovery is likely. Very rarely is a liver transplant required.

After contracting hepatitis A, your body builds immunity to the disease. A healthy immune system will prevent the disease from developing if you’re exposed to the virus