MEDICINE BLENDED ASSIGNMENT JULY 2021

 GENERAL MEDICINE DEPARTMENT - JUNE 2021 BIMONTHLY BLENDED ASSESSMENT .


M.Koushiki rn.79 
3rd sem 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) 

This is the link of the questions asked regarding the assignment:

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. 

•I have gone through the entire answer paper of
 rn. 78   from the link given in the question   and just sharing the review of each answer with my qualitative insights into what was good or bad about the answers. 
The link for the answer paper i reviewed is given here-


Q.1  Please go through one particular answer of ten students in this link:

https://generalmedicinedepartment.blogspot.com/2021/06/bimonthly-formative-and-summative_19.html?m=1
Share your peer review of each answer with your qualitative insights into what was good or bad about the answer.

answered by roll no 78 

The answer attempted is good but overall it is described briefly.

Good aspects considered by rn. 78 

•The answer reflects that the rn 78 had thoroughly gone through  the cases to be understood. 
• Correct understanding of the question given.
• Whatever the missing aspects in the case regarding the  questions were identified  and added in  the answer  such as in review 8  to which 3/5 marks  given  well presentation is lacking .
Also in review 5 - need of diagrams 
•As such even i felt these are the things missed in  the case elogs  that are reviewed by n. 78 

Points to be corrected in reviewing the case elogs

•The  processes of reviewing to be improved by taking considering of each and every question attempted in the answer paper of the students   just like in review 2 the student answer was upto the mark particularly the efficay  over placebo ,mechanism of action and indications  are well described and this could be appreciated. And could be awarded 4/5 marks in my view  rather than 3 
off course the adverse effects mentioning is out of question if its also mentioned that could be really worthy.
• The reviews are  very brief and shorter i feel atleast >5 lines can be better in reviewing answers of students   like appreciating the best presentation parts and also including the things that are missing the in answer . 
•Some points to be added in the reviews like in the following reviews 
Review 4-  5th Subquestion  is not attempted and the treatment part is incomplete .
Review 6-  mechanism of action, indications, efficacy of placebo over each pharmacological and non pharmacological interventions are not explained.
Review  8 - just like review 6 the sub question 5 is not attempted  and treatment part is incomplete .
The above mentioned points can be written in the aswer in the review part . 

Q2.
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. 

 A CASE OF HEPATIC ABSCESS PRESENTED IN SUMMER 2021  https://asjad24.blogspot.com/2021/07/a-case-of-hepatic-abscess-presented-in.html
 This was the case elog prepared  it is complete  and included all the aspects of history taking and the treatment part. 
But in the  log the institutional identity is revealed in a patient's report . It should be removed  .
The clinical data ,  history taking,  diagnosis , treatment and updates are provided .

Q.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

CASE 1: CNS case https://pallavi191.blogspot.com/2021/06/gm-cases.html?m=1

Firstly the question mentioned to give a critical appraisal of the data in the above mentioned cases but the answer written was not fulfilled as it lacks usage of terms like  completeness correctness  and any useful leads for analyzing the diagnostic and therapeutic uncertainties of the case . And there is another  case of Multisystem disease which was not mentioned in the answer.https://nikithaedam48.blogspot.com/2021/06/18-year-old-malefrom-miryalagudawho-is.html?m=1

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. 

The case links were the same as mentioned inQ2.
 •The problems list were put in writing briefly without going into detail  but a  in wide aspect the patient's all the problems can be identified and noted .yes the treatment part is mentioned , but the discussion of diagnostic and therapeutic uncertainty around each patient is no longer existing in the answer paper.

Q.5
Testing scholarship competency in  
logging reflective observations on your concrete experiences of this last month : (10 marks) 

The review was good and the reflection was well established in all aspects of the current ongoing curriculum and the effect of pandemic.I  completely concur  with  reflection.


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.





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)


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. 


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 

~http://chavvaclassworkdecjan.blogspot.com/2021/06/pancreatitis-in-chronic-alcoholic-with.html?m=1
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  for control of blood sugar level 
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. -  
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...

Treatment:

Injection PANTOP 40mg IV/OD

Injection PIPTAZ  4.5 stat  and 2.25 gm  IV/ TID

Injection LASIX 40mg IV/BD

Injection optineuron 1AMP in 100ml NS slow IV/OD

Injection NEDMOL 100ml IV/SOS

Tab PCM 650mg TID

Insulin Human actrapid - 16 IU/TI

▪︎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 : (10 marks) 
Reflective logging  of one's own experiences is a vital tool toward competency development in medical education and research. 
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.


Myself Koushiki Mekala 3rd sem 

Making an elog  is a completely  different form of learning and experiencing the  medical education compared to that of  attending hospital and seeing patients .   This elog writing is keeping clinical based competencies alive 
We are in a situation where  we cannot blame anyone of being unable to attend the college and hospital. 
Last month  I have made an elog of a patient suffering from  DECOMPENSATED LIVER DISEASE (CIRRHOSIS) with 
SPONTANEOUS BACTERIAL PERITONITIS
with HEPATIC ENCEPHALOPATHY grade I  with radial styloid fracture with k/c/o DM TYPE II .
Firstly when i got chance to make an elog  Dr Sai Vittal sir provided me  case details  then I (tele)communicated with the patient's son asked for the history of presenting illness past history  treatment history  asked for the reason his  consumption of alcohol besides his  serious condition of health  and all . By investigations we came to final diagnosis.
Im unable to understand why people go back of alcohol,  most of the cases that  i have  seen through e logs of  my classmates  and seniors from last 2 months in general medicine department   people consuming alcohol regularly and end up in being  a critical condition of health.
  There should be alot of awareness  which is lacking among the people consuming alcohol tobacco chewing smoking etc  ( excess/regularly chronic - consumption/intake/inhale  )  it just detoriates individual's health and make sick .
I thank Dr Sai Vittal sir (intern)and Dr. Rakesh Biswas sir (HOD)who is behind  us  in building scholarship competency based learning . 
This is the first time ever talking to a patient on call ( Telemedical learning experiences) .
But  we expect us to be present in college and attend clinical postings in hospital as soon as possible . 



THANK YOU SIR 
THE END OF ASSIGNMENT ______________


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