MEDICINE BLENDED ASSIGNMENT





GENERAL MEDICINE DEPARTMENT - JUNE 2021 BIMONTHLY BLENDED ASSESSMENT .


 
M.Koushiki  rn.79 
2019 batch

The following blog is an assignment that was given to us- for evaluation of our skills over the last month 

•Max Marks: 100 (5 questions in total and 20 marks for each  answer) 



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 
CASE OF PULMONOLOGY 



Quantitatively: 8/10
Qualitatively:
The answer appears to be sound, the timeline of symtomatology could me discussed more , though the flow chart representation is making to follow  and understand well , but there could be a little more informatively.  
It is important to have sufficient discussion included of the importance of the findings and their relevanace to future understanding of disease processes.The other questions were described well.


2.Link for the case study answer
CASE OF PULMONOLOGY
 https://vidya36.blogspot.com/2021/05/medicine-blended-assignment.


Quantitatively:8/10
Qualitatively:
The timeline of symtomatology presented with sufficient details but a pictorial representation of etiology  of underlysing cause if given that would be well understood.The background of the case’s history and progression described .The interventions of pharmacological and non pharmacological aspects are described well .


3. Link for the case study answer
CASE OF PULMONOLOGY


Quantitatively:7/10
Qualitatively:
The answer described enough details provided of the symptoms their episodes and other manifestations . The anatomical localization of problem is written but not the specifically identified it could be written in detail of the actual localization of problem .

4.Link for case study answer
CASE OF PULMONOLOGY 

Quantitatively: 8/10
Qualitatively:
The timeline of the symptomatology, the anatomical location and the primary etiology are mentioned clearly described. The flow chart would makes it easier to analyze and keep track of the case. A flowchart or an explanation of how the symptoms might have progressed would be helpful.The pharmacological and non pharmacological interventions  can be explained in detail.

5.Link for the case study answer 
CASE OF PULMONOLOGY


Quantitatively: 7/10
Qualitatively:
 The timeline of symtomatology and Anatomical localization and etiology are decsribed well but anu pictorial presentation of evolution of symptoms could be easier and  well understanding .The pharmacological and non pharmacological interventions are explained 
 
6.Link for case study answer 
CASE OF PULMONOLOGY 

Quantitatively:7/10
Qualitatively:
The symptomatology timeline if presented as a chart it might be easier to understand the evolution of symptoms. The causes of  electrolyte imbalance is explained well by a simple flow diagram .

7.Link for the case study answer 
CASE OF PULMONOLOGY 


Quantitatively:9/10
Qualitatively:
The symptomatology and its evolution were described in a flowchart as best part. 
The cause for her acute exacerbation was detailed and the pharmacological and non pharmacological interventions aspect was well described  just a small suggestion would be the format  like font and style of the text could be a little attractive. 

8.Link for the case study answer 
CASE OF PULMONOLOGY


Quantitatively:8/10
Qualitatively:
The timeline of symtomatology was described well and the etiology is in the form of a flowchart that was easier to understand .Pharmacological and non pharmacological interventions are also detailed.

8.Link for the case study answer 
CASE OF PULMONOLOGY 


Quantitatively: 8/10
Qualitatively:
The timeline of symtomatology is described well as point wise but the causes of etiology there could be other possibilities mentioned like exposure to paddy dust etc. The other question pharmacological and non pharmacological interventions mechanism of action were described enough.

9.Link for the case study answer 
CASE OF PULMONOLOGY 


Quantitatively:9/10
Qualitatively:
The answer described well about the symptoms its evolution the causes for acute exacerbation is described well as per my knowledge and the efficay of placebo over the pharmacological and non pharmacological interventions is decsribed well .

10.Link for the case study answer
CASE OF PULMONOLOGY 


Quantitatively:5/10
Qualitatively : 
The answer for the timeline of symtomatology  and Anatomical localization part is not mentioned and the etiology was decsribed well. The effiacy of placebo over pharmacological and non pharmacological interventions   is not attempted including the causes for acute exacerbation. Could be attempted and described well.

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. 



Question.3
Provide your critical appraisal of the captured data in terms of completeness correctness and ability to provide useful leaves to analyze the diagnostic and therapeutic uncertainties


■COMPLETENESS OF THE FOLLOWING CASE PRESENTATION 
 
•The  case has  completeness in all factors
The case begins with the chief complaint the history of presenting complaints ina a chronological order personal history is written well the vitals have been explained
•Icterus -present is shown with image 
•All Investigations  done are suggesting the   provisional diagnosis and any  changes occuring in the  patient on every day basis and uncertainties around the diagnosis have been given . 
The changes in the treatment based on the patient's status 
•Mention the patient when he was infected with
COVID and were there any kind of complications. 
■CORRECTNESS - All the data listed here  is correct as i observe 

ABILITY TO PROVIDE USEFUL LEADS ON THE PARTICULAR CASE - 
The may be post covid effect on liver causing  FULMINANT LIVER FAILURE and HEPATIC ENCEPHALOPATHY. FLH is ~30 to 50 % cause is viral infections. 



■COMPLETENESS -
•The history of the patient,symptoms and signs have been listed well. The  clinical images were provide  with the laboratory investigations.
•The  patient's treatment and daily update of his status mentioned. 
•the tests for cervical myelopathy when the provisional diagnosis of the patient was cervical myelopathy, would have been a good way of understanding the symptoms 

■CORRECTNESS OF THE DATA 
The  data that has been presented is correct 

 


■COMPLETENESS - 
•The e - log feels to be  incomplete, as there is no update on the patient after 22 June 2021 and no discharge summary 

■CORRECTNESS OF THE DATA 
The  data that has been presented is correct 

■ABILITY TO PROVIDE USEFUL LEADS - useful leads around the therapeutic uncertainties have not been provided. 
examples of such leads would include - a clinical comparison of the patient's data with the case presentation on AKI on CKD 


 
4.CVS

■COMPLETENESS - 
•The e-log is complete, the history of the patient is mentioned well, each clinical investigation has been supported with videos and accurate data, the updates on the patient have been regular. 

■CORRECTNESS- 
the data  presented is correct 

■ABILITY TO PROVIDE USEFUL LEADS
  to understand and compare the atrial  fibrillation due to hyperthyroidism check for another similar cases associated. 
 Traditionally, this classification of HF (ie, HFrEF and HFpEF) has been based on EF values as estimated with imaging modalities such as echocardiography, radionuclide ventriculography, contrast angiography, and cardiac magnetic resonance imaging.


■COMPLETENESS 
The case feels to be a little  incomplete as
 there have been no updates after 23 June, also  discharge summary is not provided 
•the rest of the case has been provided well with each investigation being dated and the changes in the treatment options 

■CORRECTNESS -
the data  is presented correctly 

■ABILITY TO PROVIDE USEFUL LEADS -
 leads around this case-not  provided a case presentation similar to this one would have been great to compare the clinical findings and the diagnosis. 

Q.4 - Please analyze the above-linked patient data by first preparing a problem list for each patient, discussing the diagnostic and therapeutic uncertainty around each patient, includes a review of the literature around the sensitivity of the topic. 


Chief complaint- Lower back pain . fever , yellowish discolouration of the eyes, 2 episodes of vomiting , three episodes of loose stool and blood in urine . 

Problem list - 
  1. Temperature - Afebrile 
  2. Icterus present 
  3. Creatinine levels in the urine - 0.6 mg/dl <normal
  4. Sodium level 132 mEq/L < the normal range. 
  5. ABG  results PCO2- 17.4 mmHg <normal range and PO2 - 119mmHG >normalrange , ph - 7.26 that is acidic 
  6. Hemogram - MCV, and MCHC of the patient are < the normal range while the MCHC is> the normal range. The patient also presents with increased RBC count 
  7. Prothrombin time is increased -24 seconds 
  8. Ketone bodies are present in the urine that indicates  ketoacidosis 
  9. Glycated hemoglobin is 6.6%which is higher than the normal range 
  10. The urine is slightly acidic, contains excessive albumin, and an increased level of sugar 
  11. C-Reactive proteins are elevated 
  12. APTT test has a higher value than the normal range 
  13. COVID -19 antibodies are positive 
  14. Total bilirubin, Direct Bilirubin, Liver enzymes are all elevated 
  15. Total serum proteins are low
  16. Altered sensorium 
Discussion of the diagnostic and therapeutic uncertainty :
▪︎ CT SCAN was done when the patient was suspected for an absence seizure, after the presentation of no responsiveness to verbal communication 
.▪︎ COVID-positive antibodies were found 
This case was one such case that explained the hepatic encephalopathy - the patient with increased liver enzymes and had an altered sensorium this caused a neurological deficit in the patient Which was treated on time 

Review of literature around the topic - 



Chief complaint- Sudden fall followed by weakness of both the lower limbs, loss of hand grip 10 days ago, bowel and bowel incontinence.

Problem list-
  1. Patient  a Known case of tuberculosis infection,  and have loss of consciousness , generalised weakness, and myalgia 
  2. Increased tone of the lower limbs bilaterally  right and left 
  3. Reduced reflexes  bilaterally in supinator muscles of the lower limb 
  4. Serum electrolytes evaluation found out that the sodium and chloride level in the given patient is s134 milliequivalents per liter and 96 milliequivalents per liter which is slightly lower than the normal range. 
  5. The lymphocytes are 14 percent  indicating a decrease than the normal range is 20-40 percent 
  6. The MRI of the brain with cervical spine shows that there is significant erosion of the inferior endplate of c5 and superior endplate of c6 
  7. An epidural abscess is seen at the level of c5-c6 that is causing the spinal cord compression and posterior displacement of the cord. 
  8. Cord edema is present  
  9. Subligamentous spread is seen as suggested from the prevertebral collection extending from c2 to d 3 
discussion of the diagnostic and therapeutic uncertainty :
 At first the prognosis was suffering from cervical myelopathy but after the MRI done,it was known that the patient had a rapidly PROGRESSING QUADRIPARESIS 
Treatment 
Day 1:
1. Inj. Optineuron 1Amp in 100ml NS IV/OD
2. Inj. Thiamine 200mg in 100ml NS IV/TID
3. ATT - according to body weight 2 tab PO/OD
4. Bp/ PR/ Spo2/ Temp charting
Day 2&3:
Same treatment followed.
Day 4:
Inj. Monocef added.

The literature surrounding the diagnosis - 




Chief complaint- Altered sensorium, morning lethargy, fever 10 days ago, Pedal oedema with anasarca and shortness of breath even at rest. 

•Problem List - 
  1. History of hypertension
  2. Pedal edema with anasarca 
  3. Known case of chronic kidney disease 
  4. Altered sensorium 
  5. morning lethargy 
  6. ECG - findings - Sinus Rhythm , Nonspecific T wave abnormality , borderline echo 
  7. Hb - 12 g/dl which is slightly less than the normal range 
  8. Lymphocytes are reduced to 11 % < the normal range 
  9. Urine examination, albumin levels of urine are present which is not normal 
  10. ultrasound report shows - CMD partially lost in the right kidney, Grade II fatty liver, simple renal cyst, 
  11. Grade II -III Renal parenchymal disorder
discussion of the diagnostic and therapeutic uncertainty :Renal Parenchymal Disorder 
The investigations taken were :
• Complete blood picture
•Complete urine examination
•ECG
•Ultrasound
•HbsAg-rapid
•Anti HCVAb -rapid
•HIV-rapid

Treatment :
1.Ivf-NS(0.0+30ml/hr)
2.Inj.LASIX(40mg/IV/TID)
3.Inj.NaHCO3(100meq in 100ml NS/IV/Stat)
4.T.NODOSIS 550mg/P.O/TID
5.BP/PR/Strict I/O Charting



Chief complaint-Distension of abdomen and shortness of breath since 5days

Problem List -
  1. shortness of breathe 
  2. Abdominal distension  
  3. hypothyroidism 
  4. feeble pulse rate 
  5. Hb - 10.3 gm/dl lower than the normal range 
  6. PCV, MCV,MCH lower than normal 
  7. Elevated levels of HbA1c- 6.7 percent 
  8. Random Blood sugar - 85 mg/dl lower than the normal range 
  9. ECG abnormal -
  10. 2d- ECHO - Pleural effusion , Mild Pericardial effusion 
discussion of the diagnostic and therapeutic uncertainty : 
 HFrEF with Atrial fibrillation 2 to ?IHDx
compare the atrial  fibrillation due to hyperthyroidism check for another similar cases associated. 

Treatment :
1. Inj. Amiodarone 150 mgIV stat (2 doses)
2.Inj.Amiodarone infusion
 1mg/min till 6hr f/b 0.5 mg/min for next 18 hours
3.Inj.clexane 40mg Sc OD


Problem list - 
  1. Pedal edema 
  2. known case of DM type 2, acute kidney injury secondary to urosepsis 
  3. Decreased urine output, burning micturition  
  4. High Blood Pressure - 170-110 mmHg
  5. Pulse rate is high - 111 beats per min
  6. In Ultrasound Examination - Right kidney had grade I Renal parenchymal disease , Left kidney had Grade II Renal parenchymal Disease 
  7. Raised serum creatinine - 3.4 mg/dl
  8. Raised Blood Urea- 65 mg/dl
  9. Serum eleclytes - Potassium level raisedd - 5.3 milli equivalents  /L
discussion of the diagnostic and therapeutic uncertainty :Acute kidney injury secondary to urosepsis with hyperkalemia ( resolved)
With anenmia of chronic disease 


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


Writing a Review  analyses the content and makes us update .This is a completely different kind of exposure to medical study that  vaires from the first year way of study.The actual foundation is in the first year but the exposure to actual medicine started now from second yr . I have actually worried and dissatisfied with the lockdown and now we being at home and unable to see the patient  directly  and feel the patient, communicate them directly.This has become a quite difficult challenge for all of us in coping up with the patients, syllabus, communication. ,off course we must find alternate ways where we can atleast comeup of  activities like elogs, telemedicine  to overcome the problem facing now .Since 1 month  through the online classes and elogs in virtual aspect of  learning the case presentations writing elogs keeping the competencies alive.
I have learnt many new terminology  while discussing the cases that i haven't heard before  and also integrating the general medicine with its actual core subjects of anatomy physiology pathophysiology and all.
Will be able to learn appreciate definitely  more when we able to see the patient live rather than 
Virtually..I have get to know that there will be a no of  diffent kinds of cases,  finding their  actual cause and the method of approaching the diagnosis by our hod sir pgs and interns caring the patient i have many things to learn with the only present option of virtual interaction. This assignment has helped me learn the basics of clinical practice like the history taking, presentation of a case, how to approach a patient etc.

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