59 K.Rithika Vasantha

                              GENERAL  MEDICINE

 BIMONTHLY BLENDED ASSESSMENT FOR JULY 2021

       

                Hello and Greetings to one and all who are currently reading my blog.

                                  This is Rithika , roll no. 59 , a 3rd semester medical student.This blog is an assessment given to me.

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

💨QUESTION 1 :  Competency based peer to peer review and assessment:

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

My question was , to go through one student's entire answer paper and share my peer review of each answer with qualitative and quantitative insights into what was good or bad about the answer.

👉Link to the question paper I chose : Roll No. 60

🌟My assessment for the first question:

• Overall ; 1 pulmonology case , 2 cardiology cases , 1 gastroenterology case , 1 case on infectious diseases , 1 nephrology case , and 4 nephrology cases were explained . 
• Each and every case was explained in a short and sweet way .
• Also briefed about the necessary / highlighted points in the case .
• All in all , she explained each and every case in tits and bits .

🌟My assessment for the second question:

• As there was no answer provided , so assessment can't be done

🌟 My assessment for the third question:

• For this question , she explained a case of CKD . 
• The patient's symptoms ; and their evolution , history , all investigations , his vitals and personal history were explained briefly to give the reader intro of the case .
• She also explained how hypertension of the patient led him into his kidney disease . 

🌟  My assessment for the fourth question:

• For this question too , the same case reference was taken , which was also explained in 3rd question , i.e a case of CKD .
• She explained in detail why each investigation and why it was taken . Examples of the investigations she explained include : CBP , CUE , ECG , USG etc.
• She also explained how each investigation is related to the patient's symptoms .
• She also told us how each investigation contributed to finalize a diagnosis and also to give us an idea as to how to teat the patient .

🌟  My assessment for fifth question:

• She explained in a short and sweet way , how telemedicine is helping her during her online classes , which are conducted due to the current prevalent pandemic .
• She also told about how she can't resist coming back to college , and to attend her clinicals , and also to have a live interaction sessions with the patients and the faculty .

💨QUESTION 2: Share the link to your own case report of a patient that you connected with and engaged while capturing his/her life events before and after illness and clinical and investigational images along with your discussion of that case.

🌟 I have taken up and made blogs of 5 cases so far. Out of which , 2 of them are renal cases. Since this month's assessment is completely dedicated to the renal cases , I'm providing links to 2 of my E-logs related to renal diseases.

👉Links to my E-logs : 

1.   A case of CKD

2.  A case of rt. shrunken kidney

👉Links to my other E- logs made this month:

1.   A case of cellulitis

2.   A case of hypoglycemia secondary to cancer

💨QUESTION 3:  To test the peer review competency of the examinees

                      My question is , to review all the cases provided as links below and provide my critical appraisal of the captured data in terms of completeness , correctness , and ability to provide useful leads to analyze the diagnostic and therapeutic uncertainities around the cases shared.

👉 First case link : AKI

🌟  Completeness : The E-log was  complete in all factors . The description of the case started with chief complaints , then history of present and past illness , treatment history , personal history , family history , physical examination , vitals , systemic examination , probable diagnosis , investigations and then treatment at the last .

Review on the case : 

• Evolution of symptomatology was described  in a much brief way .
• Systemic examination was in detail .
• Different investigations and their reports were correctly interpreted .
• She also added a note on how AKI causes a build-up of waste products in our blood and further makes it hard for the kidneys to keep the right balance of fluids in our body .

Correctness : All the data provided in the E-log is correct .

👉  Second case link : Acute on CKD 

🌟 Completeness : This case was incomplete . It did not include any treatment history , personal history , family history ; which made the case , a case without proper information .

Review on the case :

• Evolution of symptomatology was described beautifully .
• Complete history taking was not done .
• Day-to-day treatment plan was described in a detailed manner .

Correctness : All the data provided in the E-log is correct .

👉 Third case link : Coma and renal failure

🌟  Completeness : The case was complete , and included the chief complaints . history , general and systemic examinations , vitals , diagnosis and treatment .

Review on the case :

• The E-log was very well formated , which was also been provided with details of the treatment plan or the resuscitation program executed when the patient was unconscioue , which is quite impressible .
• Day-to-day treatment plan was well described .

Correctness : All the data provided in the E-log is correct .

👉  Fourth case link : Acute on CKD

🌟  Completeness :  The case in complete , in terms of description of complaints , history , general and systemic examination , vitals , investigations and treatment .

Review on the case :

• Overall look of this document pulls you to reach each and every word .
• The E-log is well organized .
• The symptomatology is also  very well written .

Correctness : All the data provided in the E-log is correct .

👉  Fifth case link :  AKI

🌟  Completeness : The case is complete , all the details like complaints , history , systemic and general examination , vitals , investigations , diagnosis , treatment ; all are well described .

Review on the case :

• The document is well organized .
• The day-to-day treatment plan and investigations are well written . 
• The general examination is also provided with relevant pictures of the patient .

Correctness : All the data provided in the E-log is correct .

👉 Sixth case link :  CKD

🌟  Completeness : The case is complete , all the details like complaints , history , systemic and general examination , vitals , investigations , diagnosis and treatment ; all are well explained .

Review on the case :

• All the sub-headings are not differentiated well , and therefore , doesn't give the reader a treat to the eye while reading . It takes our effort to find out which one is under what .
• Day-to-day treatment plan is explained very well .

Correctness : All the details provided in the E-log are correct .

💨QUESTION 4: Testing the scholarship competency of the examinees

                   My question is , to analyze the cases and provide a problems list for each case and then discuss the diagnostic and therapeutic uncertainities around solving those problems. I have to also include the review of literature around sensitivity and specificity of the diagnostic interventions mentioned and efficacy of the therapeutic interventions mentioned for each patient.

👉 First case link : AKI

🌟  Problem list :

• Lower abdominal pain , burning micturition , low back ache after lifting weights , dribbling and decreased urine output , fever ( associated with chills and rigor )  , SOB since 1 week.
•  K/C/O  HTN , RTA - trauma to head , 13 yrs back
• Irregular bowels 
• alcohol - 3 times/week
• HIS VITALS - BP : 140/70 mmHg , PR - 88bpm , SPO2 - 95% , GRBS - 113mg/dl
• In CVS examination , JVP increased
• In Per Abdomen examination , abdomen is obese , tenderness present in suprapubic pain RIF 

Probable Diagnosis :

• AKI secondary to UTI
• Associated with denovo DM-II
• With  ? rt. heart failure
• With K/C/O HTN ( not on Rx )  

       Investigations done in this case are :

• ABG - This investigation helps us to rule out if any metabolic acidosis is present or not , as most of the AKI cases are due to progression metabolic acidosis.
• USG abdomen - Is a useful tool in evaluating patients with AKI for assessing obstruction and distinguishing acute from chronic kidney diseases .

              His reports showed B/L Grade 1 RPD , Mild hepatomegaly with grade 1 fatty liver

• CBP - This is done to test  Hb levels . As kidneys produce erythropoietin , which affect Hb levels , its estimation in AKD patients is important to find anaemia.
• CUE - Helps us to find if any red blood cell casts are present , to support the diagnosis.it may also help us to diagnose septic AKI and can also predict the worsening of renal function.

             His reports showed polymicrobial flora   

• RBS - Increased sugar levels in blood will delay the recovery in AKI patients

             His RBS level was 120 mg/dl     

• LFT - AKI is a chronic complication of liver cirrhosis .
• Blood urea , Na+ , K+ , Cl+ : In cases of AKI , there is creatinine , urea buildup . There can also be hyperkalemia , and fluid overload .
• Blood smear - His RBCs were normocytic and normochromic ,  WBC - leukocytosis      

       Treatment done in this case :

• Salt restriction
• INJ. Tazar - Is used to treat bacterial infections
• INJ. Pantop - Used to reduce gastric acid secretions
• INJ. Thiamine - Provision of thiamine in AKI may reduce the incidence and severity of sepsis related AKI and thereby prevent renal failure.
• INJ. HAI - It is a human-made insulin , to treat diabetes.
• SYP. Lactulose - It is a laxative to treat constipation
• TAB. PCM - Used as analgesia
• TAB. ULTRACET - It is a stronger pain killer
• Strict I/O charting , BP/PR/RR monitoring and also GRBS monitoring         

  

👉Second case link - Acute on CKD

🌟  Problems list : 

• Lower backache and dribbling of urine since 10 days
• Increased involuntary movements of both UL - since 10 days
• Pedal edema , SOB at rest - since 3 days
• B/L pedal edema ( right > left )
• Left UL edema also present
• On RA system examination - dyspnoea grade 4 present
• On PA examination - abdomen is found to be obese
• On CNS examination , he also had slurred speech
• Reflexes of rt. and lt. biceps is 2+
• Reflexes of rt. and lt. triceps , supinator , knee is +
• Reflexes of rt. and lt. ankle is -     

     Probable diagnosis :   Acute Renal Failure 

                                        Grade 1 L4-L5 spondilodiscitis

                                        Hyperurecemia secondary to renal failure

                                         Uremia induced tremors

                                        Delerium secondary to uremic encephalopathy

Investigations done in this case:

• ECG - To screen for cardiovascular diseases
• RFT - To see the efficacy of the working capacity of the kidneys .
• CUE - It helps to diagnose kidney diseases , UTI , and other metabolic disorders . This is also to keep a check on individuals who are undergoing treatment for kidney disease . 
• Hemogram - Used to check levels of Hb levels in the blood .
• ABG -As acid-base disorders are commonly encountered in CKD patients , it is important to do this test .
• Serum electrolytes - There is hypokalemia and fluid overload in kidney disease patients .Therefore , this test helps us to find that out .
• Blood urea -There is urea and creatinine build-up in patients with kidney diseases , this test is done to find out urea levels .
• USG abdomen -Used to differentiate between acute and chronic kidney disease .
• LFT-As most of the kidney diseases are due to a complication of liver diseases , it is important to check the levela of liver enzymes .
• MRI spine-As the patient has spondylodiscitis  , MRI is done .

Treatment given in this case :

• IVF NS-Used for fluid and electrolyte replenishment .
• INJ. TAZAR-Used to treat bacterial infections .
• INJ. LASIX-Used to treat and prevent blood clots .
• INJ. PANTOP-Used to heartburns and stomach ulcers .
• INJ. 25% D WITH 10 UNITS-
• Nebulization salbutamol-Used to relieve symptoms of asthma , and COPD such as coughing , wheezing and feeling breathlessness .
• nebulization budecort -Used to prevent the symptoms of asthma , such as tightness of chest , coughing , wheezing .
• TAB. PCM-Is an analgesic .
• Foley's catheterization
• INJ. PIPTAZ -Used to treat bacterial infections .
• INJ. NEOMOL-Is a mild analgesic .
• INJ. MAI -
• INJ. OPTINEURON-Is a nutritional supplement
• Lt. U/L elevation-
• Mucaine gel-Used to treat acidity , stomach ulcer and heart burn .
• Limb bandage - crepe bandage-
• TAB. Febuxostat-Used to prevent gout attacks .
• Temp. , BP/PR/RR,  I/O  charting , GRBS charting

👉Third case link : Coma and Renal failure      

🌟Problem list :

• Fever , diarrhoea , vomiting since 5 days ( 4-5 times per day with blood discharge )
• Backpain , abdominal pain , chest pain 
• DM-II , 3 yrs on Mixtard medication
• Infection in little finger , 2 yrs ago , infected area removed
• Severe breathlessness and pain in chest region
• GRBS- 580mg/dl - given 10 units of insulin
• Altered sensorium since 1 day
• Pt. was conscious on arrival , later became unconscious - inhibition and CPR done
• ABG - Severe Metabolic acidosis
• SPO2 - 60%
• ROSC obtained after 3 cycles of CPR
• Initially BP fluctuating between 80/50mmHg and 90/40mmHg.Later  was put on NE ,then stagnant 110/90mmHg
• RR - 36 cycles/min , PR - 86bpm
• GCS - E3V4M5 before arrest , E1VTM1 after arrest , Result - E1VTM4 

                        ON DAY 6 :

• Pt had bedsores
• Complete debridement upto muscle was done 
• No prognosis
• Started antibiotics
• Physiotherapy suggested
• No improvement

Probable diagnosis :

• DKA with AKI ( ? pre renal )
• USG - pyelonephritis

Investigations done in this case :

• ABG -To rule out acid-base disorders .
• CBP -To monitor Hb and RBC levels .
• LFT-As most of the kidney diseases are due to complication of liver diseases , it is necessary to monitor the levels of liver enzymes .
• RFT-To test the efficacy and working capacity of the kidneys .
• CUE-Helps us to diagnose AKI and also predicts worsening of kidney functions .
• Bacterial culture report-Helps us to find out if there is any microbial growth ,

                    skin commensals ( micrococcal ) growth

• Serum Mg-Elevated Mg levels help us to diagnose kidney failure .
• Smear - Helps us to detect anemia or any other blood related disorder .

                    MC / Hypochromic anaemia , thrombocytopenia

• USG -To check any abdominal dilatations are present or not .
• Test for ketones-To test if any sugars are present in the urine .

Treatment done for this case :

• Dialysis was done
• INJ. Norad-Used to treat hypotension which might have occured due to sepsis .
• INJ. PIPTAZ-Used to treat bacterial infections
• INJ. Dopamine-Used to treat  low BP , CO , and improves blood flow to kidneys .
• INJ. HAI-Used to treat high blood sugar levels .
• INJ. Clexane -Is a blood thinner and is used to treat and prevent blood clots .
• INJ. NE-To treat life threatening low BP
• INJ. LECOFLOX-Used to treat infections
• INJ. Vancomycin-To treat colitis that may occur after antibiotic treatment .
• INJ. Merpenam-Used to treat skin and abdominal infections caused by bacteria and meningitis.
• INJ. Fosfomycin-Used to treat bladder infections .
• INJ. Lasix-Is a blood thinner . used to treat and prevent blood clots .
• IV-NS -Used for fluid and electrolyte replenishment .

👉 Fourth case link : Case of acute on CKD

🌟   Problems list :

• Fever since 4 days 
• Pus in urine
• DM-II since 5 yrs - on TAB. Glimi M1
• Drippling of urine , decreased output of urine, difficulty in void initially , not associated with suprapubic pain , burning micturition since 3 months
• Was told to have prostomegaly & advised TURP
• After surgery , few days later , decreased appetite , generalized weakness , drowsiness , hyponatremia , increased creatinine levels
• Now , has SOB since 4 days on exertion , increased creatinine ( 10mg/dl )
• H/O fleshy mass like & foamy passage in urine , 6 days back 

Probable dianosis:

• Renal AKI secondary to urosepsis
• B/L Hydroureteronephrosis with K/C/O DM-II since 5 yrs with Diabetic Nephropathy
• Anaemia secondary to CKD with grade 1 bed sore.

Investigations done in this case:

• GRBS-To monitor the blood sugar levels .
• Hemogram-To check the Hb and RBC levels .
• Serum creatinine , serum urea-There are increased urea , creatinine levels in kidney diseases. To monitor them , this test has to be done .
• ECG-To check the condition of the heart .
• Bacterial culture & sensitivity report-As there is urosepsis , this test helps us to know if any pus cells or any other cells are present in urine .
• Serum electrolytes-To monitor the levels of Na+ , K+ , Cl-
• ABG-Helps us to rule out if any acid-base disorders are there or not .
• Color Doppler-
• USG Abdomen-Used for assessing any obstructions or dilatations .
• Urine bag- Was found with pus cells
• NCCT KUB - B/L Hydronephrosis , severe on rt. , moderate on lt.

Treatment given in this case:

• INJ. Pantop-Used to treat GERD , heartburn , stomach ulcers .
• INJ. Piptaz-Used to treat bacterial infections .
• INJ. Lasix -Is a blood thinner . Used to treat and prevent blood clots .
• INJ. Optineuron-Used to treat nutritional defeciences .
• INJ. Nedmol-Is a mild analgesic .
• TAB. PCM-Is an analgesic .
• Human insulin actrapid-Used to reduce high sugar levels .

👉Fifth case link: AKI

🌟  Problems list :

• Loose stools, 20 episodes/day , since 20 days
• Pedal edema , since 20 days
• Abdominal distension , since 20 days
• Addicted to alcohol , & chewable tobacco 
• Pallor + , PR- 100bpm , RR - 16 cycles/min , BP -  140/90 mmHg , SPO2 - 96% , GRBS - 190mg/dl
• On PA examination - distended abdomen , inverted umbilicus, dilated veins +

Probable diagnosis :

• Alcoholic Hepatitis 
• AKI secondary to gastroenteritis
• HFrEF secondary to CAD
• Alcoholic and tobacco dependence syndrome

Investigations done on this case:

• Hemogram-done to see Hb and RBC levels .
• CUE-Helps us to diagnose septic AKI and can also predict worsening of renal function .
• LFT-AKI  is a complication of liver cirrhosis . So to confirm , this test has to be done .
• RFT-To test the efficacy and working capacity of kidneys .
• ECG-To check the condition of the heart .
• CXR-
• USG Abdomen - Used for assessing any obstructions or dilatations .
• APTT -Tells us about how long our blood will take to form a clot .
• BT/CT -Used to detect coagulation disorder , epistaxis , platelet disorder .

Treatment given in this case:

• INJ. Thiamine -To treat B1 deficiency .
• INJ. Optineuron -Used to treat bacterial infections .
• INJ. Lasix -Used to treat and prevent blood clots .
• INJ. Pantop -Used to treat GERD , heartburns , stomach ulcers .
• TAB. Aldactone -Used to lower BP , heart attacks , kidney problems .Also used to treat edema .
• Abdominal girth measurement daily
• BP/PR/TEMP. , I/O Charting
• INJ. Metrogyl -Used to treat infections caused by bacteria .
• INJ. Ciproflox -Is an antibiotic .
• INJ. Vitcofol - To treat anemia .
• TAB. Sporlac : To treat cancer chemotherapy , antibiotic treatments .
• ORS - Used to treat dehydration caused due to diarrhoea .
• TAB Loperamide - Used to treat diarrhoea .
• TAB. Ecospirin -Is an anti-inflammatory and analgesic and is used to treat pain and swelling .
• TAB. Lorazepam -To treat anxiety and sleeping problems .
• TAB. Livogen -To treat anemia , chronic blood loss and low intake of iron .
• Endoscopy - Mallory weiss tear healing phase, gastroduodenitis

👉  Sixth case link : CKD

🌟  Problems list :

• Hemorrhoids , 3 yrs back
• H/O muscle aches , since 3 yrs
• H/O fever since 20 days
• Generalized weakness since 20 days
• H/O vomitings since 3 days , with food as content .
• Has pallor

Probable diagnosis :

• CKD 
• ? Chronic interstitial nephritis secondary to plasma cell dyscariasis ( multiple myeloma - 70% plasmacytosis )

Investigations done in this case :

• ABG -To rule out any acid-base disorders
• Hemogram -To check if anemia is present
• Smear -Dimorphic anemia
• Serum electrolytes -
• Serum creatinine and blood urea -There are increased levels of creatinine and urea in kidney diseases. So , these tests are necessary to monitor them .
• CUE -To find out if any infectious cells or pus cells or any proteins are present or not .
• LFT -Kidney diseases are due to a complication of liver diseases . So , to rule out , we need to do this test .
• ECG -To check the condition of the heart .
• Bone marrow aspiration -Showed plasma cell dyscaria . probably multiple myeloma ( 70% )
• Serum B12 and iron profile -To see if any iron deficiency anemia is present .

Treatment given in this case :

• T. PAN 40- To treat heartburn , acid reflux , ulcers
• Protein powder -Nutritional supplement
• T. ZOFER -To treat nausea and vomiting
• T. Nodosis -To treat acid indigestion , heartburn , stomach upset , metabolic acidosis
• Iron supplementation after treating gastritis -To treat iron deficiency
• I/O Charting and BP/PR/RR monitoring -
• INJ. Erythropoietin -To treat low RBC levels
• T. Orofer -To treat anemia , chronic blood loss , folate deficiency , iron deficiencies .
• INJ. Optineuron -Is a nutritional supplement

💨QUESTION 5:  Testing scholarship competency in logging reflective observations on our concrete experiences of this last month.

                   My question is to reflect and share my telemedical learning experiences from the hospital as well as community patients over the last month , particularly while E- logging case reports.

🌟             My experience of telemedicine has been great. It has enabled all of us to have a virtual patient - doctor relationship . With E-logging , and integrating learnings with my current subjects , pharmacology , pathology , microbiology , I have understood the why's of the disease and its clinical presentation. I understood why a particular drug is prescribed and how it helps the patient. Telemedicine has made me step into their shoes and understand what life is with the disease.

              And to add upon , to reduce our communication gap and to give us a more detailed understanding , Dr. Rakesh sir made cases and their explanations available to us via the whatsapp group discussions , thus using the online social media platforms effectively and providing us knowledge and insights of each and every case in detail.

                Online postings have come in as a blessing in disguise to bind the students and teachers virtually ; giving a 360 degree feel of attending to patients , enhancing the learning experience , better understanding of subject by correlating theory and practicals. 

                 The case sheets given to us actually make us more inquisitive and helps us in furthering our knowledge. It has also led a profound inspect on patient-student relationship , history taking has been a bit difficult but has been thought provoking.    

              I'd like to comment the faculty for taking the initiatives and personally mentoring us.All in all, even though virtual classes were a little unconventional , inconvinient ,  we all are managing and striving hard together to make this productive and enjoy the new normal!!!

              I thank the department of GENERAL MEDICINE for giving me this opportunity and I'm grateful🙌 for it !!!!!