BIMONTHLY BLENDED ASSESSMENT OCTOBER-2021

This is Varshini reddy of roll no.25 from third semester 

The following blog is an assignment that was given to us.

Question link: https://medicinedepartment.blogspot.com/2021/10/oct-2021-formative-bimonthly-blended.html?m=1

Question 1: Please go through the case reports in the links below 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.

Answer:

Gastroenterology:

Link:  https://63konakanchihyndavi.blogspot.com/2021/10/a-case-discussion-on-chronic-liver.html

It is a case of 40 year old male with shortness of breadth, jaundice and reduced urine output. 

In terms of completeness, the case report in the above link is complete with all the required information that is needed including the clinical images, examination, investigations, diagnosis and treatment. 

In terms of correctness, the data was given correctly

In the above case report, there were certain aspects that were mentioned which were useful to analyze the diagnostic and therapeutic uncertainties around the case.

CNS:

link: https://srilekha77.blogspot.com/2021/10/blog-post.html

It is a case of 55 year old male with altered sensorium under evaluation.

In terms of completeness, the case report includes all the required information in a chronological order along with diagnosis and treatment. Discharge summary was mentioned.

In terms of correctness, the data was given correctly.

In the above case report, there was no discussion about diagnostic and therapeutic uncertainties. However, to analyze the diagnostic and therapeutic uncertainties, all the investigations, the history that was taken, examinations that were done and provisional diagnosis would become the useful leads. 

Hematology:

Link:  https://mahithguduri63.blogspot.com/2021/09/pancytopenia-under-evaluation.html?m=1

It is a case of 70year old male with pancytopenia under evaluation.

In terms of completeness, the case report was done on a daily basis in a chronological order and everything was included. Discharge summary was not included.

In terms of correctness, the data was given correctly.

In this case, the useful leads to analyze the diagnostic and therapeutic uncertainties would be the change in symptoms of the patient from day 8 and further investigations that were done.

Pulmonology, Cardiology: 

Link:  https://vamsikrishna1996.blogspot.com/2020/12/supraja-medicine-elog-nephrology-case.html?m=1

It is a case of 26 year old man with CKD on MHD.

In terms of completeness, the case report was complete, history was mentioned in a chronological order, all the investigations were included along with diagnosis and treatment. Discharge summary was not included. 

In terms of correctness, the data was given correctly.

In this case, there were some useful leads that were present to analyze the diagnostic and therapeutic uncertainties.

Nephrology: 

Link: https://bhargavikantipudirollno21.blogspot.com/2021/10/a-46-year-old-male-with-pedal-edema.html?m=1

It is a case of 46 year old male with pedal edema. 

In terms of completeness, the case report included all the previous history of the patient along with the chief complaints of the patient at present. The timeline of events in this case report were mentioned in an easy manner in a flow chart. Some of the clinical pictures and investigations were also included. The treatment or the medications that were taken by the patient were not included.

In terms of correctness, the data was given correctly.

Question 2 and Question 3: Please analyze the above linked long and short cases patient data by first preparing a problem list for each patient in order of perceived priority (based on the shared data) and then discuss the diagnostic and therapeutic uncertainty around solving those problems.

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. 

Answer: 

Gastroenterology:

Link:  https://63konakanchihyndavi.blogspot.com/2021/10/a-case-discussion-on-chronic-liver.html

It is a case of 40 year old male with shortness of breadth, jaundice and reduced urine output. 

    Problem list includes: The patient was having chief complaints of 

• shortness of breath worsening since 2 hrs ( GRADE 3-4 ) 
• palpitations 
• bilateral pedal edema - pitting type since 10-15 days.
• Abdominal distension & decreased urine output since 15 days.
• history of fever 1 week back now it was subsided. 
• He is a known case of diabetes since 6 months and was on treatment
• His appetite was decreased
• Mild icterus and edema were present
• The shape of the abdomen was distended and the umbilicus was slit shaped
• On percussion of abdomen, shifting dullness was present
• On the basis of hemogram, the patient had anemia and decreased platlet count
• From LFT, there was mild increase in bilirubin level and serum protein level was decreased 
• There was decreased level of LDH which was tested from ascitic fluid
• Serum creatinine and blood urea levels were increased

The investigations that were done in this patient were RFT , LFT , HEMOGRAM , CUE , ECG , USG - Abdomen , BGT , ABG , VIRAL SEROLOGY , CHEST X RAY, 2D echo.

The provisional diagnosis of this case report- Chronic renal failure and hepato renal syndrome or chronic kidney disease

The treatment that was given to this patient includes- Fluid restriction, Salt restriction , Tab Lasix, Tab Metalazone, Tab Thiamine, Syrup Lactulose, Tab Rifagut, Protein powder, Tab Udiliv,  2-3 egg whites / day

In this case report, the diagnostic uncertainty was whether the patient is having Hepato renal syndrome(HRS) or underlying CKD. It was concluded based on increased Na+ levels in urine secondary to lasix infusion and it may also be secondary due to tubular injury. Serum creatinine level decreased intially after lasix infusion which was favoring CKD, but again its level increased which may be due to HRS or secondary to patient decreased water intake. 

To know whether it was CKD or HRS, the plan was to continue the patient on diuretics for the next 3-5days. 

CNS:

link: https://srilekha77.blogspot.com/2021/10/blog-post.html

It is a case of 55 year old male with altered sensorium under evaluation.

The problem list inlcudes: The patient was having chief complaints of 

• Altered sensorium since since one day and history of headache and he took two hypertensive tablets .
• The patient was having a past history of CKD(since 6 years) for which he was on medication since then.
• The patient was a known case of hypertension since 6 years
• On inspection, the shape of the abdomen was scaphoid
• The speech of the patient was slurred, he was not oriented to place and non coherent
• Tone was decreased in both right upper and lower limbs
• Power of right upper and lower limbs was 3/5
• Biceps, triceps, supinator reflexes of left upper limb and triceps reflex of right upper limb were increased 
• Supinator, knee and ankle reflexes of right upper and lower limbs were decreased
• From impression of MRI brain plain, there was acute infarct in both sides of pons and left midbrain 

The investigations that were done in this patient are MRI brain plain, 2D echo, RFT, ECG.

The provisional diagnosis of this case report- Right sided Hemiparesis and altered sensorium secondary to infarcts in the brain?

Treatment that was given to this patient includes head end elevation, Inj. mannitol, Tab ecospirin, Inj Optineuron, tab amlong, Physiotherapy for right upper limb and lower limb.

There were no diagnostic uncertainties in this report, diagnosis was concluded based on the examinations and investigations.

The patient was discharged to have surgery at another center.

Hematology:

Link:  https://mahithguduri63.blogspot.com/2021/09/pancytopenia-under-evaluation.html?m=1

It is a case of 26 year old man with CKD on MHD.

The problem list includes: The patient was having chief complaints of 

• Shortness of breadth since 20 days 
• Leg pain on walking since 20 days 
• Pedal edema since morning(pitting type) 
• He had history of blood transfusion, and had complaints of red colored urine after transfusion and fever for 2 days.
• On inspection, pallor was present 
• On the basis of hemogram, the patient had pancytopenia 
• From the LFT, the patient had increased bilirubin level

The investigations that were done in this patient are Hemogram, LFT, serum electrolytes, serum creatinine, blood urea, T3, T4, TSH, CUE.

The provisional diagnosis of this case report- Pancytopenia under evaluation

? Vit B12 deficiency 

The treatment that was given to this patient includes Inj. methylcobalamine, Inj. iron sucrose, and monitoring of vitals

Diagnostic uncertainties: After 8 days of treatment with the above medication, patient complained about fever spikes and not able to walk due to shivering in the legs during fever spike, then Ceftriaxone was added to the above treatment plan.

On day 11, Patient had 2 episodes of vomiting and suddenly became breathless with profuse sweating ,cold peripheries ,feeble pulse.

Based on the assessment, there was ?Septic shock, ?cardiogenic shock, Heart failure and severe anemia.

The further plan to manage this case was to provide O2 inhalation, ionotropic support- on noradrenaline, they started to give piptaz and PRBC transfusion was advised. 

Pulmonology, Cardiology: 

Link: https://vamsikrishna1996.blogspot.com/2020/12/supraja-medicine-elog-nephrology-case.html?m=1

It is a case of 26 year old man with CKD on MHD.

The problem list includes: The patient was having chief complaints of 

• Vomitings for one and half month
• high blood pressure
• Intermittent shortness of breadth on walking for long distance 
• spasm of both calves since 5-6yrs monthly twice/thrice only night times due to which he used to get up from his sleep
• he had noticed pedal edema in between dialysis and also shortness of breath 2days after each dialysis associated with orthopnea PND and insomnia 
• When he came for his regular dialysis then, he complained of shortness of breath even at rest, abdominal tightness and pedal edema
• Serum urea and creatinine levels had increased.
• Total protein and serum albumin level had decreased, Serum Alkaline phosphatase level had increased.

The investigations that were done in this patient were prothrombin time, ABG, LFT, ECG, chest X-ray, CBP, 2D ECHO, Lipid profile

The provisional diagnosis of this case report- CKD ON MHD WITH HTN WITH B/L TRANSUDATIVE PLUERAL EFFUSION SECONDARY TO HD

The treatment that was given to this patient includes- Salt and water restriction, Inj. augmentin, Tab nocardia, pantop, lasix, orofer xt, shelcal, nodosis, zofer and monitoring of vitals.

There were no diagnostic uncertainties in this report, diagnosis was concluded based on the examinations and investigations.

Question 4: Share the link to your own case report this month of a patient that you connected with and engaged while capturing his her sequential life events before and after the illness and clinical and investigational images along with your discussion of that case. 

Answer:

Link: https://varshinireddychada.blogspot.com/2021/10/general-medicine-e-log.html

Question 5 : Reflective logging  of one's own experiences is a vital tool toward competency development in medical education and research. 

Answer:

   For our semester, offline classes were started from august itself, but we didnt have our clinical postings at that time. From this month( october) our clinical postings had started for real. For my batch our first clinical posting was GM, and I was very excited as I got a chance to see the patients and to know them. On our first day of posting, we visited ICU, Nephrology and CKD ward of GM. There were a lot patients who were admitted at that time. Dr. Rakesh Biswas sir had explained us about the problems that all the patients had in the nephrology ward in a detailed manner, and taught us how to interpret and diagnose the disease without even looking at the investigations. 

    I got a chance to get to know a patient in CKD ward and make an elog of that patient. I was nervous at the beginning before asking questions to the patient, but I could manage to get all the information that is required because of the co-operative nature of the patient and his guardian. 

   In this whole process, our PGs and interns had helped us a lot on how to interact with the patients, how to examine them, and how to make an elog.

   I thank Rakesh biswas sir for giving us such an opportunity of interacting with patient and make us do an E-LOG for our better understanding. This month has been great as we got a chance to attend the patients in the hospital in person and by this our learning experience has improved.

I am looking forward for such a great learning experiences in the future. 

                     -THANK YOU-