MEDICINE DEPARTMENT PAPER FOR JULY 2021 BIMONTHLY BLENDED ASSESSMENT
This is the link of the questions asked regarding the assignment:
http://medicinedepartment.blogspot.com/2021/07/medicine-paper-for-july-2021-bimonthly.html?m=1
Question.1.Go through one question of 10 students given in the link mentioned below and give a peer review of the quantitative marking and the qualitative insights on what was good or bad in the chosen blog I'm sharing my peer review of the answers with quantitative marking input as well as qualitative insights into what was good or bad about the answer , basically providing a feedback based on theme of scholarship of integration in medical education and research.
1.Link for the case study answer https://pravallikagade41.blogspot.com/
Question.1.
Go through one question of 10 students given in the link mentioned below and give a peer review of the quantitative marking and the qualitative insights on what was good or bad in the chosen blog
I'm sharing my peer review of the answers with quantitative marking input as well as qualitative insights into what was good or bad about the answer , basically providing a feedback based on theme of scholarship of integration in medical education and research.
1.Link for the case study answer
55 yr male with weakness in lest UL/LL, deviation of mouth to the right side, involuntary micturition, difficulty in swallowing along with slurred speech.
It is really admirable how my fellow worker has presented the case by way of a blog. Everything is in a systematic order, all the examinations and investigations are prerequisites for diagnosis. She made sure everything is in the correct order and asked appropriate questions in history taking which is important to know the patient's condition.
Question 2. share the link to your own case report of a patient that you connected with while capturing his or her sequential life events before and after illness and share the clinical images with the discussion of your case.
https://pravallikagade41.blogspot.com/2021/07/55-yr-male-with-weakness-in-left-ulll.html
Question 3 : (Testing peer review competency of the examinees)
Please go through the cases in the links shared above and provide your critical appraisal of the captured data in terms of completeness, correctness and ability to provide useful leads to analyze the diagnostic and therapeutic uncertainties around the cases shared.
Patient centered data around the theme of renal failure patients with AKI, CKD and acute on CKD,
captured by students from 2016 and 2019 batch in the links below:
Patients with low back ache and renal failure :
AKI :
COMPLETENESS :
•The case was presented capturing the patient's sequential life events regarding illness also investigations done and the xray images are provided .
CORRECTNESS:
•Though the basic information provided in the log, the case presented is seems to be incomplete .
• The case history description was not clear and could be presented better.
•The track of the patient's daily update is not seen and is the patient discharged or not what's his current situation is unable to understand.
•Also the reasons for his complaints are not described just like sudden onset of low back pain after lifting weight.
• And the the final diagnosis is not mentioned
These are the points neet to be corrected.
USEFUL LEADS TO ANALYZE THE DIAGNOSTIC AND THERAPEUTIC UNCERTAINTIES :
Any useful leads are not provided in the log
The provisional diagnosis made is AKI Secondary to UTI.
Acute kidney injury is a rapid (days to weeks) decline in the kidneys’ ability to filter metabolic waste products from the blood.
Impaired baseline renal function plays a predictive role for development of AKI in UTI patient.
COMPLETENESS:
The case log has details of the patient's complaints and history of present illness , past illness all the investigations shown with images
CORRECTNESS :
The date of admission is not mentioned.
All the data presented is correct.
USEFUL LEADS TO ANALYZE THE DIAGNOSTIC AND THERAPEUTIC UNCERTAINTIES :
What is the actual cause for the patient's renal failure though the patient is n/k/c/o DM ,HT,CVA?
The diagnosis is Acute renal failure (intrinsic)
Grade 1 L4-L5 Spondylodiscitis ,Multifocal infectious Spondylodiscitis
Hyperuricemia 2° to Renal failure
Uraemia induced tremors( resolved)
Delerium 2° to septic /Uremic encephalopathy (resolving)
Patient with coma and renal failure :
COMPLETENESS :
The case is presented in the log with complete required details of the patient's complaints, present and past history of illness and the treatment given with updates of patient well-being.
CORRECTNESS:
The provided data is correct but an investigation report is revealing the institutional identification that could be corrected just by cropping the image.
USEFUL LEADS TO ANALYZE THE DIAGNOSTIC AND THERAPEUTIC UNCERTAINTIES :
●How the bed sores formed related to patient's condition any reason
●Did bedsores developed before admission or in the process of undergoing treatment in hospital?
In the past the patient had an infection of little finger and the infected part is removed .
●How diabetes mellitus type 2 can be related to bed sores ?
●The patient's altered sensorium and comatose state is due to ?
●How the kidneys got effected within no longer 3yrs ago has diagnosed with dm type 2 (followed regular diet and evaluation of the condition)also Her GRBS(general random blood sugar) was 580mg/dl for which 10 units of insulin was infused.
COMPLETENESS:
The log prepared has all the details and requirements .
CORRECTNESS: The provided data is correct. But in treatment update part might be date is incorrect written as 02 - 06- 21 instead of 02- 07-21
USEFUL LEADS TO ANALYZE THE DIAGNOSTIC AND THERAPEUTIC UNCERTAINTIES :
The final diagnosis made as
INFECTIVE ENDOCARDITIS
with AV VEGETATIONS WITH MODERATE AS SEVERE AR. withAKI
with ?UREMIC ENCEPHALOPATHY ? SEPTIC ENCEPHALOPATHY
with ULCER OVER SOLE OF RIGHT LEG
withHYPOALBUMINEMIA ? ALCOHOLIC LIVER DISEASE
with ACUTE MULTIPLE INFARCTS IN BILATERAL CEREBRAL AND CEREBELLAR HEMISPHERES
the impact of aki on infective endocarditis?
Patients with acute on CKD :
COMPLETENESS:
•The case log is complete with the history of the patient,symptoms and signs have been listed well.
•The clinical images were provide with the laboratory investigations.
•Whether the patient is discharged or still in hospital his status is missing in the log also the treatment daone on every day of the patient's hospital stay should also be mentioned.
CORRECTNESS:
The data provided in the log is correct.
USEFUL LEADS TO ANALYZE THE DIAGNOSTIC AND THERAPEUTIC UNCERTAINTIES :
The therapeutic uncertainties can not be understood as the treatment done on each day of hospital stay is not provided.
COMPLETENESS:
•The date of admission not seen.
The case begins with the chief complaint the history of presenting inner switches in chronological order personal history is well written the vitals have been explained with the help of clinical charts.
The updates between 10 to 14/07 is not seen.
CORRECTNESS:
The data provided in the log is correct.
USEFUL LEADS TO ANALYZE THE DIAGNOSTIC AND THERAPEUTIC UNCERTAINTIES :
There are some useful leads provided in the case log .
COMPLETENESS: The case log is presented well but the discharge date or discharge summary not mentioned
• investigations with clinical images are seen for the diagnostic approach.
CORRECTNESS:
The data provided in the log is correct.
USEFUL LEADS TO ANALYZE THE DIAGNOSTIC AND THERAPEUTIC UNCERTAINTIES :
no useful leads to analyze the diagnostic and therapeutic uncertainties are mentioned.
Patients with AKI :
COMPLETENESS:
• There is no update of patient after 12/07
The updates are good enough till 12/07 with the daily progress of the patient's condition.
CORRECTNESS:
The data provided is correct
USEFUL LEADS TO ANALYZE THE DIAGNOSTIC AND THERAPEUTIC UNCERTAINTIES :
If there was a referral for cross consultation by psychiatric department it might be useful like the patient is having alcoholic and tobacco withdrawal syndrome and tremors occuring during treatment might be subsided by psychiatric medications.
Ni useful leads to analyze the diagnostic and therapeutic uncertainty is provided.
COMPLETENESS: The discharge summary is not seen otherwise the case log is complete with the history of the patient,symptoms and signs have been listed well.
CORRECTNESS:
The data provided is correct .
USEFUL LEADS TO ANALYZE THE DIAGNOSTIC AND THERAPEUTIC UNCERTAINTIES :
Any useful leads not provided.
The diagnosis made was Acute kidney injury secondary to urosepsis with hyperkalemia ( resolved)
With anenmia of chronic disease
COMPLETENESS:
The case is presented in the log with complete required details of the patient's complaints, present and past history of illness and the treatment given with updates of patient well-being.
CORRECTNESS :
The date of admission is not mentioned.
All the data presented is correct.
USEFUL LEADS TO ANALYZE THE DIAGNOSTIC AND THERAPEUTIC UNCERTAINTIES :
Not mentioned
How did the patient's pancreas got effected causing acute pancreatitis?
Alcohol withdrawal syndrome if present consultation of psychiatric and medications can also be provided based on the patient's condition .
Question 4 : Testing scholarship competency of the examinees ( ability to read comprehend, analyze, reflect upon and discuss captured patient centered data as in their 'original' answers to the assignment for May 2021):
Please analyze the above linked patient data (links are same as in question 3)by first preparing a problem list for each patient (based on the shared data) and then discuss the diagnostic and therapeutic uncertainty around solving those problems. Also include the review of literature around sensitivity and specificity of the diagnostic interventions mentioned and same around efficacy of the therapeutic interventions mentioned for each patient.
Sensitivity: the ability of a test to correctly identify patients with a disease.
Specificity: the ability of a test to correctly dentify people without the disease
Sensitivity refers to true positive rate (correctly diagnosed as disease)
Specificity refers to true negative rate.
Patients with low back ache and renal failure :
AKI :
Problems list :
1. Complaints of lower back pain ,burning micturition, dribbling / decrease in urine output ,fever ,sob
2. k/c/o HTN ( not on medication)
3. Blood Urea level 128 mg/dl ( normal 12- 42) serum creatinine 5.9 ( 0.9 - 1.3)
4. NORMOCYTIC NORMOCROMIC with Leukocytosis
Acute kidney injury( AKI) 2° to UTI, associated with Denovo - DM -2
INVESTIGATIONS:
Hemogram,complete urine examination, complete blood picture ,2D echo, Chest X ray,renal and liver function tests ,HbA1c,ABG report,Bacterial culture and sensitivity report
Treatment:
•Salt restriction - This was done in order to prevent excess stress on the Kidneys
•INJ. TAZAR -Antibiotic for UTIINJ.
•Pantop- Reduces acid in the stomach Inj. •Thiamine -Tab. PCM - paracetamol for the fever
•TabMyoril - Muscle relaxant Tab Shelcal - prevents osteoporosis
All the investigations lead to the diagnosis of the case and better treatment of the patient. Hence, no diagnostic uncertainties were found.
Problems list:
1. On presentation. -
Lower backache since 10days
dribbling of urine since 10days
Pedal edema since 3days
SOB at rest since 3days
Increased involuntary movements of both upper limbs.
2. On Respiratory examination -
Dyspnoea Grade 4
3. The blood urea is very high lying between 167(11/7) 126(14/7) 125(17/7) * normal is 12 -42 mg/dl.
4. also The serum creatinine levels raised 3.2 (11/7)
5.1(14/7) 2.8(17/7)
6. Also anemic
7. Increased uric acid levels - 11.0
INVESTIGATIONS:
-ABG analysis ,complete blood picture, LFT, KFT, Bacterial culture and sensitivity report, hemogram ,X rays ,MRI scan ,2D echo, CBP
Diagnosis:
Acute renal failure (intrinsic)
Grade 1 L4-L5 Spondylodiscitis ,Multifocal infectious Spondylodiscitis
Hyperuricemia 2° to Renal failure
Uraemia induced tremors( resolved)
Delerium 2° to septic /Uremic encephalopathy (resolving)
Treatment:
IVF - NS-0.9% @100ml/hr
• Inj. Tazar 2.25gm I.V -TID belongs to the 'Antibiotics' class of drugs, primarily used to treat bacterial infections. contains two medicines, namely: Piperacillin (Penicillin antibiotic) and Tazobactam (beta-lactamase inhibitor). Piperacillin belongs to the class of 'Penicillin antibiotics.'
• Inj. Lasix 40mg I.V -BD
•Nebulization Salbutamol -4th hourly
• Inj. Pantop 40mg I.V -OD : proton pump inhibitor, decreases secretion of hcl
indicated as prophylaxis given along with other medications to prevent ulcers
• Tab. PCM 650mg -TID
• Foleys catheterization
• Temperature ,Bp, PR Charting hourly
• Strict IO Charting
•GRBS -12th hourly
• Inj.25% D with 10units of insulin IV -slow for 1hr
All the investigations lead to the diagnosis of the case and better treatment of the patient. Hence, no diagnostic uncertainties were found.
Patient with coma and renal failure :
Problems list:
1. On presentation. -
Fever and Diarrhea since 5 days( 4 to 5 times a day with blood discharge).Back pain( 5 days ago) with abdominal pain and chest pain. Also
2. On examination-
Initially her BP was fluctuating between 80/50 and 90/40. Later she was put on Noradrenaline infusion after which her BP was stagnant at 110/90.
• GRBS(general random blood sugar) was 580mg/dl
INVESTIGATIONS:
-ABG analysis ,complete blood picture, LFT, KFT, Bacterial culture and sensitivity report, hemogram ,X rays ,MRI scan ,2D echo, CBP..
Why did the patient got Cardiac arrest and an immediate cpr is performed reason for cardiac arrest further investigations could be done to rule out like an angiogram.
All the investigations lead to the diagnosis of the case and better treatment of the patient. Hence, no diagnostic uncertainties were found.
Problems list:
1. On presentation. -
abdominal distension from the past 7 days.
From the past 5 days, he complains of Constipation and has not passed stools since 5 days.
He also complains of altered Sleep patterns from the past 5 Days
He has hiccups since today morning
He also Complains of pedal edema grade
In past:
2Alcoholic Liver Disease,
AKI secondary to UTI on CKD, secondary to ? Diabetic nephropathy,
Hepatic encephalopathy grade 2
On examination:
There is icterus and pedal edema.
Provisional Diagnosis:
Infective endocarditis?
Hepatic encephalopathy?
INVESTIGATIONS:
CUE,Hemogram, RFT, LFT, ECG, 2D echo, ABG, serum electrolytes, urinary sodium,chloride,potassium, Bacterial culture and sensitivity report, CBP, MRI Brain etc...
Final diagnosis
INFECTIVE ENDOCARDITIS
WITH AV VEGETATIONS WITH MODERATE AS SEVERE AR
WITH AKI
WITH ?UREMIC ENCEPHALOPATHY ? SEPTIC ENCEPHALOPATHY
WITH ULCER OVER SOLE OF RIGHT LEG
WITH HYPOALBUMINEMIA ? ALCOHOLIC LIVER DISEASE
WITH ACUTE MULTIPLE INFARCTS IN BILATERAL CEREBRAL AND CEREBELLAR HEMISPHERES
All the investigations lead to the diagnosis of the case and better treatment of the patient. Hence, no diagnostic uncertainties were found.
Patients with acute on CKD :
Problems list:
1. On presentation. -
Chief Complaints of Fever since 4 days Pus in the Urine
On examination - bladder - Increased frequency
2. On investigations Creatinine - 3.8 mg/dl
Urea - 70mg/dl
NORMOCYTIC NORMOCROMIC anenmia present in the course of treatment.
The blood urea and serum creatinine levels are fluctuating above the normal values indicating the impaired function of kidneys.
On further investigations:
Bilateral Hydroureteronephrosis, severe on right side and moderate on left.
Both dilated in entire course with tortuosity of lower portion
Urinary bladder shows diffuse circumferential wall thickening( 6 -7mm)
Tiny calcific focus in pelvis on right side - outside the urinary tract - phlebolith
No obvious obstructing lesion in urinary tract
INVESTIGATIONS:
-Hemogram ,X rays ,ECG ,Fever Chart ,Bacterial culture and sensitivity report, CBP, Serum creatinine, serum sodium,potassium,chloride .Blood urea ,ABG,2D echo etc...
▪︎All the investigations lead to the diagnosis of the case and better treatment of the patient. Hence, no diagnostic uncertainties were found. Though therapeutic aspect cannot be ruled out as the treatment update is not provided.
Problems list:
1. On presentation
chief complaints of Shortness of Breath
2ysr back -diagnosis of Chronic renal failure was made
Diabetes Mellitus from the past 7 years Hypertension from the past 7 years
2. On examination:
Bowel Movements- IrregularEdema of feet present Dyspnoea - present
3.In investigations:
•Fasting blood sugar -Elevated
•Post Lunch Blood Sugar -Elevated
•Erythrocyte sedimentation rate-Elevated
•Complete blood Picture- Hb lower than normal •Liver Function Test increased ALP
Diagnosis:
HFrEF secondary to CAD; CRF
All the investigations lead to the diagnosis of the case and better treatment of the patient. Hence, no diagnostic uncertainties were found. But the treatment update is not seen.
Problems list:
1.complaints of:
Pedal edema since 3 days.
Decreased urine output since 3 days.
H/o vomitings and loose stools 5 days ago lasted 3 days and subsided.
2.In past :
Shortness of breath;-
since 15 years..
pneumonitis with Type 1 Respiratory Failite,
3.On examination :
Spo2 :- 85% on room air
4.Investigations
• loss of albumin in urine
Blood urea. Serum Creatinine
04/06 194. 10
05/06. 197. 10.3
06/06. DIALYSIS
07/06. DIALYSIS
09/07. DIALYSIS
10/06. 55. 4.8
14/06. 3.9
15/06 hb decreadsed 10gm/dl
RA/RA/IVC dilated
HbA1c 7.5 poor control
2-D Echo Found to have a right heart failure without any left heart failure
Diagnosis
- CKD ? Chronic interstitial nephritis secondary to plasma cell dyscariasis, (multiple myeloma - 70% plasmacytosis).
Bone marrow aspiration was done to know if the patient has multiple myeloma.The case presentation is complete ,with the laboratory investigation reports and the image of electrophoresis.Data provided is sufficient to diagnose the disease.
All the investigations lead to the diagnosis of the case and better treatment of the patient. Hence, no diagnostic uncertainties were found
Patients with AKI :
Problems list:
1.complaints of:
loose stools since 20 days
Pedal edema (bilateral pitting edema up to knee)
since 20 days
Abdominal distension since 20 days which is progressive.
2.In past:
regular alcohol intake since 15 years (180ml per day), chewable tobacco 1-2 per day since 15 years
3. On examination :
Pallor+
Decrease in albumin level
INVESTIGATIONS:
Hemogram,CUE ,CBP ,RFT ,LFT ,ECG .
CXR PA view,X ray .inj.Thiamine 100 mg
USG Abdomen ,APTT ,BT /CT.
Diagnosed as:
ALCOHOLIC HEPATITIS ,
AKI SECONDARY TO ACUTE GASTROENTERITIS
HFrEF SECONDARY TO CAD
ALCOHOLIC AND TOBACCO DEPENDENCE SYNDROME
All the investigations lead to the diagnosis of the case and better treatment of the patient. Hence, no diagnostic uncertainties were found. But as alcoholic and tobacco dependence syndrome is present a psychiatric medications and consultation could be recommended.
QUESTION 5
Testing scholarship competency in logging reflective observations on your concrete experiences of this last month write an essay for 10 marks on the above topic
In the last month , we began our general medicine internship postings. Due to the ongoing pandemic, classes were taken online which was making it slightly challenging for us to follow. Nevertheless, it has been a great change for us to come back to posting in person and to be informed about the day to day happenings of the hospital. They help us apply our subjective knowledge in a clinical setting which helps to form a bridge between both. Although the wards are extremely chaotic, professors and PG’s have been doing their best to pass on their knowledge to us and it is very encouraging for interns to be present in a clinical setting. It helps us understand how much practical knowledge differs from reading books and to experience it all as interns has been a refreshing experience. We greatly appreciate the opportunity given to us and are trying to utilize it thoroughly. I have learnt several practical aspects of being a doctor. I also got to understand the grievances of patients and how important it is to provide a healing atmosphere for their recovery. Our HOD of General Medicine, Dr. Rakesh Biswas has been explaining each and every single case along with the pathophysiology of symptoms and further complications. Discussions on the cases with my peers and juniors helped me understand multiple ways to go about relating the symptoms to different organ systems and in understanding the etiology of the diseases. Interactive learning is taking up a huge role in our academics and it will make me a better part of a medical team. I thank our General medicine department for presenting us this great opportunity.
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