Case #4

Student details , SANTU SAHA , 
IQCMC , Durgapur , India
Class - General Medicine ward ( 4th semester )

Age : 19 years
Sex : Male
Occupation : College student
State : West Bengal
Year : 2017

#Chief complains

1. Recurrent fever
2. Pain around left iliac crest

#History of present illness

Since 3 months, the patient is suffering from recurrent fever. When he started taking medicine the fever subsided. But as he stopped taking the medicines​ , he again developed fever. There is no particular timing of his fever. He has developed hepatomegaly and along with  sign of pallor. It seems that he also has pleural effusion.

And , due to arthralgia , he was unable to extend at the level of his Right elbow.

#History of past illness

Regarding the Pain
1. Onset       : 20 - 25 days ago,  for 4 - 5 days ,then followed by fever
2. Position   : Pain around left iliac crest
3. Quality     : continous pain
4. Relieving or Aggravating factor : no such factor
5. Severity   : intolerable
6. Timing     : no specific timing

He never had any major or minor surgery operated on him.
Also , 2.5 months ago , he was diagnosed with Typhoid fever.
Then after medication, he was apparently well for the next 15 days. He suddenly developed malaise followed by a series of recurrent fever. 

Subcutaneous spot of bleeding could be seen in left arm.

A supernumerary nipple can also be seen on the left half of abdomen along the milk line (Line of Schultz).

#Family history

Grandmother - breast cancer
Aunt - died undiagnosed
Father - died at the age of 28 years,  due to rectal cancer

#Drug history 
No allergy for drugs.

#Personal history

Appetite                     : normal
Sleep                          : normal 
Built                            : weak and slim
Rate of respiration   : High (> 30 breaths per minute)
Pulse rate                  : High (95 pulses per minute)
Heart rate                  : High ( tachycardia)
Tremors, Cyanosis, Clubbing  : absent

#Findings

USG report of whole abdomen shows that liver is enlarged in size, gallbladder is contracted, spleen is normal in size with echotexture.
Mild free fluid is also seen in the peritoneal​ cavity.
Thus, hepatomegaly and mild Ascites has been inferred.

#Peripheral Smear Findings

RBC : RBCs predominantly Normocytic Normochromic. Moderate anisopoikiliocytosis seen. Moderate polychromasia seen , nRBCs - 17/100
WBC : Total count within normal limits . Blasts - 40 % , Neutrophil - 26 % , Lymphocytes - 28 % , Eosinophils - 1% ,Monocytes - 5%
Platelet : Reduced on smear

Finally , when immunophenotyping was performed it has been observed that it's a case of precursor B cell acute lymphoblastic leukaemia ( Pre B-ALL) with a aberrant CD33 expression.

#And now , here are few University questions, related to the topic , that are often asked :

Pathology

1. Leukemia definltion

2. FAB classifications

3. Peripheral blood picture and laboratory diagnosis of AML , CML , ALL , CLL

4. Aleukemic leukemia- short note 

5. Leukemoid reaction Leukemia are not very easy to differentiate-comment

6. Philadelphia chromosome

7. Diagnostic criteria of blastic phases of chronic myeloid Leukemia

General Medicine

1. Causes of generalized lymphadenopathy

2. Clinical staging of Hodgkin lymphoma

3. Peripheral blood picture in patient of CML in blast crisis

4. Difference between NHL and HL

5. CML - First line therapy 

#Treatment of the patient

At present patient is in remission ( disease free) after first induction therapy. But MRD positive means minimal residual disease present. He is taking second phase of chemotherapy in day care.

#Method in use : The Berlin-Frankfurt-Munster (BFM) 2002 ALL Protocols

#Details of the treatment method

Acute Lymphoblastic Leukemia in Children

A Brief Review of the Internationally Available Protocols

The following medicines are available in the first edition of the Essential Medicines List for children.

Cytotoxic medicines

Complementary  List  

A) allopurinol   Tablet:  100  mg  to  300  mg.  

B) asparaginase   Powder  for  injection:  10  000  IU  in  vial.  

C) bleomycin   Powder  for  injection:  15  mg  (as  sulfate)  in  vial.  

D) calcium  folinate   Injection:  3  mg/ml  in  10‐ml  ampoule.  

Tablet:  15  mg.  

E) chlorambucil   Tablet:  2  mg.  

F)cisplatin   Powder  for  injection:  10  mg;  50  mg  in  vial.  

G) cyclophosphamide Powder  for  injection:  500  mg  in  vial.  

Tablet:  25  mg.  

H) cytarabine   Powder  for  injection:  100  mg  in  vial.  

I) dacarbazine   Powder  for  injection:  100  mg  in  vial.  

J) dactinomycin   Powder  for  injection:  500  micrograms  in  vial.  

K) daunorubicin   Powder  for  injection:  50  mg  (as  hydrochloride).  

L) doxorubicin   Powder  for  injection:  10  mg;  50  mg  (hydrochloride)

in  vial.  

M) etoposide   Capsule:  100  mg.  

Injection:  20  mg/ml  in  5‐ml  ampoule.  

N) fluorouracil   Injection:  50  mg/ml  in  5‐ml  ampoule.  

O) mercaptopurine   Tablet:  50  mg.

P) methotrexate   Powder  for  injection:  50  mg  (as  sodium  salt)  in  vial.

Tablet:  2.5  mg  (as  sodium  salt).  

Q) procarbazine   Capsule:  50  mg  (as  hydrochloride).  

R) vinblastine   Powder  for  injection:  10  mg  (sulfate)  in  vial.  

S) vincristine   Powder  for  injection:  1  mg;  5  mg  (sulfate)  in  vial.

Under the BFM 2002 ALL Protocols

Outline of Induction has been given below in the diagram

# Prednisone prephase therapy: Patients receive oral prednisone on days 1‐7

and one dose of methotrexate (MTX) intrathecally (IT) on day 1.  

# Induction/consolidation therapy, protocol I: Patients are randomized to 1 of 2

treatment arms. 

Induction therapy has 2 phase, then consolidation and again 2 phase reinduction. Every phase is different from other. Total 6 months of therapy

And after 2 months of treatment, the test reports are :

#Bibliography

1) https://clinicaltrials.gov/ct2/show/NCT00114348

2) http://ascopubs.org/doi/full/10.1200/jco.2013.48.6522

3) WHO - Cytotoxic medicines ( Review )

And if there is any idea , do let me know in the comments section below and Thanks everyone , for viewing my page .

Case #3

Student details , SANTU SAHA , 
IQCMC , Durgapur , India
Class - General Medicine ward ( 4th semester )

Age : 21 Years 4 Months
Sex : Male
Occupation : College student
State : Assam
Year : 2017

Chief complains

1. Swelling in the anal triangle of Perineum
2. Intense pain
3. Difficulties in performing daily like walking , standing , sitting
due to the pain

History of present illness

Regarding the Pain
1. Onset : 4-5 days ago , the pain became intense
2. Position : above anus , in the anal triangle
3. Quality : continous pain
4. Relieving or Aggravating factor : relieve from pain in
Lithotomy position while the pain aggravated while standing
and walking
5. Severity : intolerable
6. Timing : no specific time
7. Treatment : minor operation

History of past illness
1. Infrequent constipation for last 1 years
2. Minor trauma in an accident 2 years ago
Family history

1. Uncle and a close cousin

Clinical diagnosis

# It has been found that the patient is having , Fistula in Ano.
# Histopathology report of the specimen extracted (Fistulous
tract in the perianal area) suggest that it is a Chronic Non-
specific inflammatory lesion.

Findings and Suggestions

# Injection of radio-opaque fluids like Lipodol , into a sinus or a fistula ( i.e. sinogram or fistulogram ) will indicate the cause of the sinus or fistula by delineating its course.
# Fistula-in-ano is often seen in more than one member in a family.
# If there were any history of Colloid carcinoma of rectum , then it may have produced anal fistula in later stage.
# Traumatic fistula like faecal fistula , may occur after operation or after accidental injury to certain.

And finally , Thanks a lot , to the patient for giving his valuable time and long time co-operation !

My 1st year MBBS experience

After clearing my Medical entrance, I got admission in a medical school . Joining medical school was like dream come true. I was really happy and excited about a completely new experience. I feel proud to be a part of this medical community , as I can now actually do something directly for the people of my country.

Every year lakhs of science stream students prepare for Medical entrance,  but only a handful of them cross the exam. Things are getting harder day by day due to increased competition and quality of education. Internet has made things easier, and knowledge available for everyone anytime.

I still remember, when I was in 1st year MBBS. It was really difficult for to me cope with the new syllabus. For the first 2 months , i couldn't understand what to do and what not to.
In reality I didn't know how to study.
In the beginning I used to fail in most of the PCT ( part completion test ). I could not even secure 50% mark in these exams. It was really confusing as I had no idea  , what the professor is going to ask and which topic is more important. And finally after some time I somehow managed to adjust myself with the situation. Whatever be the situation just say yourself “ I will never give up ” . I decided to make plans before implementation of any idea. In the beginning all my plans failed , be it Plan A or Plan Y. After , soon I started improving. Soon results came in my favour. I started learning from my mistakes. Each time i was becoming better and more powerful than earlier. i started making better , more improved and smart Plans.
Well said by Dr. Vishram Singh

“To learn from previous experience and change accordingly, makes you a successful man.”

Finally , my 1st year mbbs professional exam approached. I didn't panic this time, instead i gave my exam with confidence , without thinking much about negative consequences.
After 1 month , it was the time for declaration of exam's result. I was out of control , i didn't know how to control my mind and emotions.

Finally , at 7:30 pm , i got to know that our result has been declared. I was severely shivering. One of my friend asked me for my Roll number; this time i was out of this world. I , then gave my Roll number to him and asked to check the result. But , one more disaster was waiting for me , NO Internet Connection. I could feel my heartbeat and all signs of Tachycardia. After 5 minutes I got internet connection, and the page reloaded. I saw in the next page : PASS .

What a relief,  this word was the Word of the Day in my Dictionary for that day. I passed all the subjects , with better marks than I expected . I discovered , Physiology as the strongest subject with more marks , than other subjects .I was still shivering and full of adrenaline rush. I could not understand,  how to celebrate my success , shall I Dance , Jump from a tower or shall I take a mike and announce everywhere about this news.
Now , I was gonna be a Senior. I will be in 2nd year MBBS. New subjects,  New experience and One more challenge.

At the end , I just wanna say one thing !

                         “ A Goal Without A Plan, Is Just A Wish ”.

This was my experience of 1st year in my medical school. You can also share your feelings in the comment section below. I will happy to listen your reactions about the article.
Thanks everyone for viewing my page .

Medical mnemonics

Hi , guys what's up , it's been so long that I haven't posted anything in my blog. Today , I am gonna write about mnemonics.

ANATOMY

# Synovial joint
Praying Hard Provides Children Strong Belief.

P ~ Plane joint
H ~ Hinge joint
P ~ Pivot joint
C ~ Condylar joint
S ~ Saddle joint
B ~ Ball and socket joint

# Examples of saddle joint
Cat Is Sleeping in SADDLE JOINt

C ~ Calcaneocuboidal joint
I ~ Incudomalleolar joint
S ~ Sternoclavicular joint
t ~ 1st carpometacarpal joinT

# General points to describe any body part
AV LMN

A ~ Arterial supply
V ~ Veinous drainage

L ~ Lymphatic drainage
M ~ Muscle
N ~ Nerve supply

# Internal thoracic / mammary artery branches
Pari Pari Mujhe Perfect Superman Se Abhi Milao

P ~ Pericardiophrenic artery
P ~ Perforating branches
M ~ Mediastinal branches
P ~ Pericardial
S ~ Superior epigastric artery
S ~ sternal
A ~ Anterior thoracic artery
M ~ Musculophrenic artery

# Human body parts that 45 cm or 18 inches in Length
Very FAST

V ~ Vas differns
F ~ Femur ( for 6 feet person )
A ~ Aorta ( complete part )
S ~ Spinal cord / Sartorius muscle
T ~ thoracic duct / Transverse colon

# Normal anatomical location of Nipple ( in a non-sagging breast )
Remember : 44

4 ~ 4th intercostal space
4 ~ 4 inches feon median plane

# Sites of constriction in Esophagus
ABCD

A ~ Aortic constriction
B ~ Bronchial constriction
C ~ Cervical constriction
D ~ Diaphragmatic constriction

# Relations of thoracic part of the Esophagus
ART of Left Diaphragm

A ~ Arch of Aorta
R ~ Right pulomary artery
T ~ Trachea

L ~ Left artrium / Left principal bronchus
D ~ Diaphragm

# Development of Diaphragm
Remember : Social Democratic Party of germany × SPD of BODY WALL

S ~ Septum transversum
P ~ Pleuroperitoneal membrane
D ~ Dorsal mesentry of Esophagus
BODY WALL ~ from body wall , peripherally

# Contents of Superior Mesdiastinum
Try To Eat The Soap And Vitamins Now

T ~ Thymus
T ~ Trachea
E ~ Esophagus
T ~ Thoracic duct
S ~ Sympathetic trunk
A ~ arch of aorta + its 3 branches  ( Arteries )
V ~ brachiocephalic vein + superior vena cava ( Veins )
N ~ vagus + phrenic nerve ( Nerves )

# Contents of Posterior Mediastinum
DATES

D ~ Descending aorta
A ~ Azygos vein + Accessory Azygos vein + hemiazygos vein
T ~ Thoracic duct
E ~ Esophagus
S ~ Sympathetic trunk

Case #2

Student details , SANTU SAHA , 
IQCMC , Durgapur , India
Class - General Medicine ward ( 3rd semester )

Age              : 74 years
Sex               : Male
Occupation : retired 

State             : West bengal
Year              : 2016

Chief complains
1. Pain in loin region 
2. Radiating pain towards Right lateral thigh from gluteal region
3. Loss of appetite

History of present illness

1. Onset : Two weeks ago, the pain became intense
2. Position : lower loin region 
3. Quality : continuous deep pain
4. Relieving or aggravating factors : pain aggravated when he moved forward or tried to bent
5. Severity : intolerable 
6. Timing : mainly during morning hours
7. Treatment : pain relieving injection received

History of past illness

1. Recent minor trauma in left hip joint
2. Gall bladder calculi also found , but not removed yet
3. Heart related disease

Family history 
His mother had  Spondyloarthropathy.

Confirmatory test : Schober's test also performed (17cm)

Diagnosis

# X- ray report suggests that there are osteophytes in LV1-5 and a typical bamboo shaped vertebral arrangement is also present
# Disc degenerative changes also , found at this level .

# Also , there is reduced size of sacroiliac joint parts .

# Lumbar lordosis reduced too.

All these findings suggests,  Spondyloarthropathy , ankylosing spondylitis.

Case #1

Student details , SANTU SAHA , 
IQCMC , Durgapur , India
Class - General Medicine ward ( 3rd semester )

Age - 56 years
State - West bengal 
Year - 2016

Chief complains
The chief complains of the patient are : 
1. Swollen dorsum of both the foot 
2. Difficulties in breathing
3. Distended abdomen

History of present illness

Since, 2 months , the patient is having difficulties in breathing. 
He also has swollen dorsum of foot of both legs. He noticed this for the first time 15 days back in his feet.
He also has obesity.

Past history

He never had any major or minor surgical operated on him. 
He was apparently normal 2 months ago.

Hypertension           : Present 

Diabetes                    : Present

Edema                       : Present  (dorsum of foot)

TB                               : absent

Respiratory distress    : Present

Increased heart size also found (as per X ray flim) and there is heart failure.
Jugular venous pulsations can also be observed.

Drug history 
No allergy for drugs.

Personal history

Appetite                     : normal
Sleep                          : normal 
Built                            : Obese
Rate of respiration   : 19-22 times per minute  ( abnormal )
Tremors                     : absent

Findings

The problem seems to be due to his obesity. He also has got hypertension and heart failure as the heart is not pumping efficiently.  The edema also developed due this reasons only , as the venous return is not proper and there is accumulation of fluid in the interstitial spaces , again due to increased hydrostatic pressure. 
If any form of yoga or exercise, can be done to reduce the size of his abdominal obese , below 80cm of circumference,  then he can probably live a normal life again.