The following assessment is for my internship completion for the month of June. The link below is that of the question paper.
https://medicinedepartment.blogspot.com/2021/06/medicine-department-paper-for-june-2021.html?m=1
Question 1: Competency tested for Peer to peer review and assessment.
Answer - I will be assessing the answer to the third question -
“WHAT COULD BE THE CAUSE OF HER ACUTE EXACERBATION ?”
“May be due to INFECTION( infection causes inflammation in lungs leading to narrowing of airways , blockage may occurs due to swelling and mucus production”Qualitative - PATIENT DOES NOT HAVE A HISTORY OF FEVER. HER TLC IS 5700. I DONOT THINK IT IS AN INFECTION, PER SE. THERE IS H/O SEASONAL EXACERBATION SINCE YEARS.
Quantitative - 5/10
“3) causes for Acute exacerbation are caused by a viral or bacterial lung infection, but they may also be triggered by things or situations that make it difficult for you to breathe, such as smoking or being exposed to smoke or air pollution.”
Qualitative - PATIENT DOES NOT HAVE A HISTORY OF FEVER. HER TLC IS 5700. I DONOT THINK IT IS AN INFECTION, PER SE. THERE IS H/O SEASONAL EXACERBATION SINCE YEARS.
We might need eosinophil, lymphycyte and neutrophil count to justify this.
Quantitative - 5/10
“he cause of acute Exaberation in this patient is probably due to generalised weakness due to the drugs or due to upper respiratory tract infection.”
Qualitative - PATIENT DOES NOT HAVE A HISTORY OF FEVER. HER TLC IS 5700. I DONOT THINK IT IS AN INFECTION, PER SE. THERE IS H/O SEASONAL EXACERBATION SINCE YEARS.
We might need eosinophil, lymphycyte and neutrophil count to justify this.
YES, THIS CAN BE DUE GENERAL DECLINE IN PATIENT HEALTH.
Quantitative - 5/10
“it could be due any infection”
Qualitative - PATIENT DOES NOT HAVE A HISTORY OF FEVER. HER TLC IS 5700. I DONOT THINK IT IS AN INFECTION, PER SE. THERE IS H/O SEASONAL EXACERBATION SINCE YEARS.
We might need eosinophil, lymphycyte and neutrophil count to justify this.
Quantitative - 5/10
“Ans : The cause of acute Exacerbation in this patient is probably due to generalized weakness due to the drugs or due to upper respiratory tract infection.”
Qualitative - PATIENT DOES NOT HAVE A HISTORY OF FEVER. HER TLC IS 5700. I DONOT THINK IT IS AN INFECTION, PER SE. THERE IS H/O SEASONAL EXACERBATION SINCE YEARS.
We might need eosinophil, lymphycyte and neutrophil count to justify this.
Quantitative - 5/10
“Cause due to current acute exacerbation is due to infection (bacterial, viral)”
Qualitative - PATIENT DOES NOT HAVE A HISTORY OF FEVER. HER TLC IS 5700. I DONOT THINK IT IS AN INFECTION, PER SE. THERE IS H/O SEASONAL EXACERBATION SINCE YEARS.
SHE IS A K/C/O BRONCHIECTESIS. MOST PEOPLE SEEM TO BE MISSING THIS POINT.
We might need eosinophil, lymphycyte and neutrophil count to justify this.
Quantitative - 5/10
“Recently, her HRTC showed signs of bronchiectasis. [A condition where bronchial tubes of lungs are permanently damaged, widened and thickened. These damaged air passages allow bacteria and mucus to build up and pool in the lungs blocking the airways] This could be a trigger factor for the current acute exacerbation.”
QUALITATIVE - YES, THIS COULD BE TRUE. I STILL DONOT AGREE WITH THE INFECTION PART. IT COULD BE NARROWING OF AIRWAYS DUE TO BRONCHIECTASIS
QUANITITATIVE 8/10
- REVIEW 8 https://08arshewarpavankumar.blogspot.com/2021/05/a-40-year-old-male-with-complaints-of.html
QUALITATVE AND QUANTITATIVE SAME AS REVIEW 1-6
“Respiratory infection, being responsible for approximately half of COPD exacerbations. Common bacterial pathogens of acute exacerbations include Haemophilus influenzae, Streptococcus pneumoniae and Moraxella catarrhalis.[7]Less common bacterial pathogens include Chlamydia pneumoniae and MRSA.
Allergens, e.g., pollens, wood or cigarette smoke, pollution[5]
Toxins, including a variety of different chemicals[5]
Air pollution[citation needed]
Failing to follow a drug therapy program, e.g. improper use of an inhaler”
QUALITATIVE - ALLERGENS COULD BE THE CAUSE. BUT BRONCHIECTASIS OCCURS IN A CHRONIC LUNG PATHOLOGY. THIS PATIENT HAS A LONG STANDING HISTORY OF SEASONAL EXACERBATIONS. THIS EXCERBATION COULD BE BECAUSE OF COR PULMONALE - WHERE THERE IS A HEART FAILURE - BECAUSE IT IS NOT REDUCING WITH HER REGULAR MEDICATION AND IT IS FOLLOWED BY A KIDNE FAILURE.
QUANTITATIVE 7/10
- REVIEW 10 https://blendedasessmentmadhukumar.blogspot.com/2021/05/medicine-blended-assesment-may.html
Exposure to allergens which could make it a possible occupational hazard
Infections by Moraxella, H. influenzae or Pneumococcus (Bacterial), Influenza, Rhinovirus, Coronavirus (Viral)
Dust or pesticides exposure”
QUALITATIVE AND QUANTITATIVE REVIEW SAME AS REVIEW 1-5
Question 2 : 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.
The following case is of a 19 F who I encountered on my Unit’s OutPatient day. I remember examining her in the OP, feeling a sense of pleasure when I was the first to find her splenomegaly.
The history in the blog made by the students of 2019 batch was sent by me, after i properly spoke to the patient, typed down the history and forwarded that along with the reports of the investigations.
I have been in contact with the patient’s attenders. The sent me pictures of the following.
Question 3 - 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.
1. CASE 1 https://nikithaedam48.blogspot.com/2021/06/18-year-old-malefrom-miryalagudawho-is.html?m=1
THE DATE WISE DEPICTION OF HISTORY, CLINICAL OBSERVATIONS, LAB INESTIGATIONS AND THE INTERVENTION IS THE CHERRY ON TOP OF THE CAKE AS IT MAKES THE DATA CONCISE YET DETAILED.
THE ONLY ISSUE IS WE DONOT KNOW THE DEFINITE CAUSE FOR HIS JAUNDICE IN THE BEGINNING AND A SUDDEN MIRACULOUS RECOVERY WITH N-ACETYL CYSTIENE.
IN SUCH CASES, THE CLINICAL PATHOLOGY CAN BE LOCALISED WITH CLINICAL EXMINATION AND LATER CONFIRMED USING RADIOLOGY.
CLINICALLY, THE BICEPS REFLEX IS 3+, CONFIRMING THAT THE LESION IS ABOVE C5.
IT IS VERY COMMENDABLE THAT THE PATIENT’S CONDITION AFTER DISCHARGE FROM THE HOSPITAL WAS FOLLOWED UP.
IN SUCH PATIENTS, IT IS IMPORTANT TO MONITOR WEIGHT AND ABDOMINAL GIRTH DAILY TO MONITOR THE ALTERATION IN EDEMA.
DATA CAPTURE IS PRETTY. ACCURATE.
TREATMENT FOR ATRAIL FIBRILLATION IS - AMIODARIONE (ANTI-ARRHYTHMIC) AND CLEXAME (ANTI-COAGULANT) TO PREVENT ANY THROMBUS FORMATION AS A.FIB HAS A HIGH RISK FOR THROMI FORMATION
WHY WERE MAGNEXFORTE AND NORFLOX GIVEN ? CANDIDA WAS ISOLATED, SO SHOULDNT AN ANTI-FUNGAL BE GIVEN ?
ALSO, MAGNEXFORTE AND NORFLOX HAVE THE SAME BACTERIAL COVERAGE, THEN WH BOTH ?
Q4: 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.
1. CASE 1 https://nikithaedam48.blogspot.com/2021/06/18-year-old-malefrom-miryalagudawho-is.html?m=1
PROBLEM LIST
1. LOW BACK ACHE SINCE 7 DAYS
2. FEVER SINCE 5 DAYS
3. JAUNDICE SINCE 3 DAYS
4. VOMITING, LOOSE STOOLS, BLOOD TINGED URINE - SINCE A DAY BEFORE PRESENTATION
5. FEATURES OF DM SINCE 2 MONTHS
6. DECREASING GCS (AFTER ADMISSION)
7. ANURIA
8. SEIZURES
7. COAGULOPATHY
LOW BACK ACHE, BLOOD TINGED URINE - COULD BE BECAUSE OF THE RENAL CALCULUS
JAUNDICE, VOMITING, LOOSE STOOLS, COAGULOPATHY AND COME MOSTLY DUE TO LIVER FAILURE.
THERAPEUTIC UNCERTAINITY -
THE PATEINT SHOWED INDIRECT HYPERBILIRUBINEMIA BUT THERE WAS NO HEMOLYSIS
PORPHYIA SUSPICION WAS CLEARED, AND IT WAS RULED OUT
GASTROENTEROLOGY OPINION ADICED LIVER TRANSPLANT
MIRACULOUSLY - NAC WHICH REPLENISHES THE GUTATHIONE STORES WORKED .
COULD THIS BE A PARACETAMOL POISONING ?
PROBLEM LIST
1. B/L LOSS OF HAND GRIP
2. PARAPLEGIA
3. BOWEL AND BLADDER INCONTINENCE
4. TB
LESION FROM THE LEVEL OF C4 (SPONDYLITIS)
THE ONLY WAY TO TREAT THIS WAS ATT AND SURGICAL DECOMPRESSION.
PROBLEM LIST
1. ALTERED SENSORIUM
2. FEVER
3. PEDAL EDEMA WITH ANASARCA (CREAT ?11-14.8)
4. SOB GRADE 4
5. 5 YEARS AGO, INCIDENTAL FINDING - SERUM CREAT WAS 3
NO FOLLOW UP STOPPED AFTER 2015
6. K/C/O HTN SINCE 5 YEARS
K/CO CKD
FEVER CAUSED AKI LEADING TO SOB (FLUID OVERLOAD CAUSING PULMONARY CONGESTION) - INCREASED NITROGEN PRODUCT ACCUMULATION CAUSING ENCEPHALOPATHY
THERAPEUTIC UNCERTAINITIES
AMOUNT OF SODIUM BICARBONATE IN SUCH CASES.
BECAUSE IT CAN CAUSE PARADOXICAL CELLULAR ACIDOSIS. HOW DO WE DECIDE HOW MUCH BI-CARB THAT IS TO BE ADMINISTERED ?
IS STRICT INPUT/OUTPUT CHARTING EVER DONE ?
PROBLEM LIST
1. ABDOMINAL DISTENSION
2. SOB GRADE 3
3. HYPOTHYROIDSIM
AMIODARONE IS THE DRUG OF CHOICE FOR AF. BUT WE DONT USE IT WHEN AF IS OLD BECAUSE OF THE RISK FOR THROMBO-EMBOLIC PHENOMENON DUE TO AF AS AF HIGHLY INCREASES THE RISK FOR THROMBO-EMBOLIC PHENOMENON
HOW OLD WAS THE AF ? HOW DO WE KNOW WHEN IT IS NEW ONSET ?
Q 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.
My first day in medicine departement was 3 June 2021.
I remember how scared I was because I was late for the first day of my internship. I reached the ICU, had no idea what to do, how to do it.
On the first day, i learnt how to connect and disconnect an i.v. set, and start i.v. fluids.
Gave a few i.v..injections when the cannula was on.
I learnt how to give CPR on my first night duty.
Learnt how to perform suction, connect o2, type discharge summaries.
Night duties, ICU duties and Nephrology duties were when i learnt the most.
I first placed a cannula on a female who was brought to the casuality with seizures. I remember being very scared, but i did it because PGs guiding me were the most patient, i aspire to be that patient to my juniors.
On the same day i tried to take out an ABG sample, was not successful. It was an anxiety inducing experience because in casuality there are a lot of people watching you do.
I remember not knowing how to disconnect a urobag, I felt extremely embarassed.
But I have come a long way.
Now I am confident about taking samples, examining patients (except nervous system examination) taking their history or in general, communicating with them.
There is so much pain and hope at the same place. It hit me hard especially when the son of a comatose 45 F was talking to her as if she was completely alright, I realised that I had grown indifferent to pain that patients and their relatives feel.
This realisation made me feel extremely guilty because it was originating from a position of authority. Since that day, i have always made sure to try my best to comfort the patients and their attenders, whenever I can.
I remember how scared I was because I was late for the first day of my internship. I reached the ICU, had no idea what to do, how to do it.
On the first day, i learnt how to connect and disconnect an i.v. set, and start i.v. fluids.
Gave a few i.v..injections when the cannula was on.
I learnt how to give CPR on my first night duty.
Learnt how to perform suction, connect o2, type discharge summaries.
Night duties, ICU duties and Nephrology duties were when i learnt the most.
I first placed a cannula on a female who was brought to the casuality with seizures. I remember being very scared, but i did it because PGs guiding me were the most patient, i aspire to be that patient to my juniors.
On the same day i tried to take out an ABG sample, was not successful. It was an anxiety inducing experience because in casuality there are a lot of people watching you do.
I remember not knowing how to disconnect a urobag, I felt extremely embarassed.
But I have come a long way.
Now I am confident about taking samples, examining patients (except nervous system examination) taking their history or in general, communicating with them.
There is so much pain and hope at the same place. It hit me hard especially when the son of a comatose 45 F was talking to her as if she was completely alright, I realised that I had grown indifferent to pain that patients and their relatives feel.
This realisation made me feel extremely guilty because it was originating from a position of authority. Since that day, i have always made sure to try my best to comfort the patients and their attenders, whenever I can.
I performed 3 ascitic taps, took numerous samples, learnt how to fast-track paper work so patients can be treated faster, placed a central venous catheter, struggled to be upto date with all patients in the ward but failing at it.
I am leaving with the thought that this is where i have started to learn practical/clinical medicine and there is a long way to go and I am looking forward to that.
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