Bimonthly Blended Assignment for July 2021

Link to Question Paper

http://medicinedepartment.blogspot.com/2021/07/medicine-paper-for-july-2021-bimonthly.html?m=1

Question 1: Competency tested for Peer to peer review and assessment : 

Please go through one student's entire answer paper from this link, the one who is closest to your own roll number :

http://medicinedepartment.blogspot.com/2021/07/2019-batch-medicine-department-online.html?m=1

and share your peer review of each answer with your qualitative insights into what was good or bad about the answer. 

Answer Q1)

After going through the answer paper of one of my close junior which is available here

https://mohammedwahaaj11.blogspot.com/2021/07/bimonthly-assignment-of-medicine-for.html

- I could actually see the effort he kept in reading, comprehending and understanding the concepts and there by reviewing the answers of the May assignment

- Also I like the way he presented his insights in the form of a Pie Chart. 

- He also neatly described the answers in short and comprehensive manner and there by making a clear idea of what he was thinking. 

- It looks he had enjoyed the experience in the logging the patient centered data and understanding the basic pathophysiology of the disease and knowing the principles of the therapeutic interventions being done for that patient in terms of efficacy, cost and as requirement for the patients. 

Question 2-4: 

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 :

https://laharikantoju.blogspot.com/2021/07/58-year-old-male-patient-elog-lahari.html?m=1

Acute on CKD :

http://srinaini25.blogspot.com/2021/07/srinaini-roll-no-33-3rd-semester-this.html

CKD :

https://krupalatha54.blogspot.com/2021/07/a-49-yr-old-female-with-generalized.html?m=1

Past E log similar to last case :

casereports.bmj.com/content/2009/bcr.03.2009.1726

Patient with coma and renal failure :

https://ananyapulikandala106.blogspot.com/2021/06/a-35yr-old-female-elog.html

https://pallavi191.blogspot.com/2021/06/gm-cases_30.html?m=1

Patients with acute on CKD :

https://kavyasamudrala.blogspot.com/2021/05/medicine-case-discussion-this-is-online.html?m=1

https://rishikakolotimedlog.blogspot.com/2021/07/45-year-old-male-with-chief-complains.html?m=1

https://krupalatha54.blogspot.com/2021/06/this-is-online-e-log-book-to-discuss.html?m=1

Patients with AKI :

https://keerthireddy42.blogspot.com/2021/07/43-yr-old-male-of-nalgonda-came-to.html?m=1

https://casescape.blogspot.com/2021/06/acute-kidney-injury-secondary-to.html?m=1

http://chavvaclassworkdecjan.blogspot.com/2021/06/pancreatitis-in-chronic-alcoholic-with.html?m=1

Question 2: Share the link to your own case report 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 2)

http://srinaini25.blogspot.com/2021/07/srinaini-roll-no-33-3rd-semester-this.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 

Answer 3)

AKI 

https://laharikantoju.blogspot.com/2021/07/58-year-old-male-patient-elog-lahari.html?m=1

Over view 

A 58 year old male patient came to casualty with chief complaints of:

- lower abdominal pain: 1 week

 -burning micturation:1week

- low back ache after lifting weights

-dribbling / decrease of urine out put:1week

-fever :1 week

- SOB , rest :1week  

Apprisal

Case history was taken well and examination was very well done... Sequential evaluation of case is apprisiable 

Negative points 

It would be better if fever chart is added as it was treated with strict temp and IO monitoring as it would be better understood improvement of the case was not well mentioned

My Analysis

This is a case of Acute kidney injury( AKI) 2° to UTI, associated with Denovo - DM -2

With ? Right HEART FAILURE,

With K/C/O - HTN ( Not on Rx)

-AKI causes a build-up of waste products in your blood and makes it hard for your kidneys to keep the right balance of fluid in your bodyand return of creatinine to the base line and symptoms less then 3 months indicating it to be a AKI

Acute on CKD :

http://srinaini25.blogspot.com/2021/07/srinaini-roll-no-33-3rd-semester-this.html

Over view 

A 75yr old male patient ,labourer by occupation ,came to casuality with Cheif complaints of 

• 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 since 10days .

Apprisal

I would not find any points to be highlighted . History was taken well 

Negative points

There are no clinical pics of the symptoms like pedal edema.

Proper chronological order of symptoms apperance was not done 

Fever chart was not included.

No IO charting was done though it was told it should be strictly monitored

My Analysis

This is case of 

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)

CKD :

https://krupalatha54.blogspot.com/2021/07/a-49-yr-old-female-with-generalized.html?m=1

Over view

A 49 yr old female , mother of 2 children, who is a house wife, apparently asymptomatic 13 yrs ago and then she noticed mass per anum with bleeding , went to hospital and diagnosed as haemorrhoids and got operated.

- Since 3 yrs she has history of muscle aches, for which she is using NSAIDs.

- She has h/o fever 20 days back, got treated in the local hospital, and 

- Since 20 days she has generalized weakness.

- She also has h/o vomitings since 3 days, with food as content, non - projectile , non bilious.

Apprisal

History was taken well.

Good lab work clear evaluation was done 

Negative points

There are no clinical pics of the symptoms like pedal edema.

Proper chronological order of symptoms apperance was not done 

Fever chart was not included.

No IO charting was done though it was told it should be strictly monitoredit would have been better if urine was sent for eosinophils for interatial disease

My Analysis

This is  case of CKD ?

Chronic interstitial nephritis secondary to plasma cell dyscariasis, (multiple myeloma - 70% plasmacytosis).

Patient with coma and renal failure 

https://ananyapulikandala106.blogspot.com/2021/06/a-35yr-old-female-elog.html

Overview

A 35 yr old female with 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.

Apprisal

Very well presented 

With good fever charting with all the necessary information.

History was taken detailed way 

Follow up was good 

All the tests were properly done 

Negative

I could not find the negative data in the elog 

My analysis

It could be the hypoxia which could have caused the permanent brain damage which was the reason for her vegetative state . Subjectively she was told better but objectively no improvement was Seen. Hospitalisation has increased the infection to the bed sore it would have been better if discharged early as it was permanent damage and was impossible to treat anyway

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 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. 

Answer 4)

•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 :

https://laharikantoju.blogspot.com/2021/07/58-year-old-male-patient-elog-lahari.html?m=1 

•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 UTI

Inj.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.

Acute on CKD :

http://srinaini25.blogspot.com/2021/07/srinaini-roll-no-33-3rd-semester-this.html

•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 :

https://ananyapulikandala106.blogspot.com/2021/06/a-35yr-old-female-elog.html

•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.

3. 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.

https://pallavi191.blogspot.com/2021/06/gm-cases_30.html?m=1

•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 

2. In past:

Alcoholic Liver Disease,

AKI secondary to UTI on CKD, secondary to ? Diabetic nephropathy,

Hepatic encephalopathy grade 2

3. 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 :

https://kavyasamudrala.blogspot.com/2021/05/medicine-case-discussion-this-is-online.html?m=1

•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.  

3. 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.

https://rishikakolotimedlog.blogspot.com/2021/07/45-year-old-male-with-chief-complains.html?m=1

•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- Irregular

Edema 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.

https://krupalatha54.blogspot.com/2021/06/this-is-online-e-log-book-to-discuss.html?m=1

•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 :

https://keerthireddy42.blogspot.com/2021/07/43-yr-old-male-of-nalgonda-came-to.html?m=1

•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 : (10 marks) 

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

A sample answer to this last assignment around sharing your experience log of the month can be seen in one student's  answer to Q10 in the  May 2021 assignment in the link below:

https://drsaranyaroshni.blogspot.com/2021/05/assignment-patient-centred-learning.html?m=1

Please reflect on and share  your telemedical learning experiences from the  hospital as well as community  patients over the last month particularly while you were E logging their case report while even in the hospital or perhaps when locked down at home.

Answer 5)

It has been 2 months 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.