General Medicine : My experiences with neuronal and general cellular pathologies with CBBLE and PaJR

Hello! I am a Medical student from India. I embarked on my journey in Medical School in September 2019, months before the pandemic brought significant changes in our lives and created a world as we see it today. 

Through this blog post, I aspire to share my experiences with Case Base Blended Learning Ecosystems, And PaJR. 

To share this journey we would have to begin at the very beginning. 

The beginning of the second wave of the pandemic marked my initial encounter with a patient. As the entire learning was shifted to an online mode of teaching, so were our Medical school postings. 

During the first two weeks of our postings, we were "Effectively desensitized "as one would say. By means of a video conference, our entire cohort of 200 medical students viewed our professors, residents and interns traversing the intensive care unit and wards, patient by patient. They elucidated the circumstances that cause the present medical condition of the patient and guided us on how to take patients and how to review the literature for each case. 

This was my initial experience witnessing patients beyond the confines of a textbook, we took up cases under the guidance of our seniors, who guided us through each step of patient care. 

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Every case I encountered represented a textbook in itself. For instance one of my earlier cases included a 19-year-old female with acute onset shortness of breath, with a history of menorrhagia, and a  diagnosis of hypothyroidism at the age of 10. 

Given the lockdown at that time, our seniors facilitated the attainment of the clinical images of the patient, portraying pallor, hyperpigmented knuckles raised JVP and mild purpura. As a second-year medical student, it was captivating to see words from the textbook come to life. 

Additionally, this experience highlighted the very important distinction between sympathy and empathy as my seniors interacted with the patient and guided them through the process. 

It was my initial encounter with concepts such as pancytopenia, and myelodysplastic syndrome, and going into the world of research articles provided an opportunity to grow as a medical student beyond the confines of the textbook. 

The patient was referred to the department of obstetrics and Gynaecology and was treated for abnormal uterine bleeding with the help of progesterone-only pills, while the pancytopenia was managed with the help of nutritional supplements of folic acid, cobalmin and nicotinamide. The patient was followed up every week. 

Here is the link to that case. 

https://rishikakolotimedlog.blogspot.com/2021/07/19-year-old-female-with-shortness-of.html

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The following cases were taken in person and were crucial in building my history-taking skills, and presentation of research articles. 

This case included a 48-year-old male, with a history of diabetes, hypertension,  acute onset shortness of breath, progressive orthopnoea with a background of renal disease 

Upon examination, there was pedal oedema and dyspnoea. further investigation revealed heart failure with reduced ejection fraction secondary to CAD and CRF. 

This was the first case that led, me to the art of reviewing the literature surrounding the patient's symptoms and management.

At first, I was asked to look into the development of heart failure in the context of chronic kidney disease and comprehend the role of beta blockers help in the management of such a patient. It was during this time that I grasped the significance of presenting articles in various formats according to their relevance (for instance the PICO format ) herby effectively communicating information that would be useful in the management of the patient. 

Here is the link to the following case with relevant discussion: 

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

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Another noteworthy case that exemplified a characteristic presentation of a case of tuberculosis. It enforced the very common saying that rare diagnoses are rarely right. 

https://rishikakolotimedlog.blogspot.com/2021/07/chief-complaints-41-year-old-male-came.html

In this particular instance, a patient diagnosed with retroviral disease presented with a chronic cough accompanied by expectoration persisting for a duration of 4 months. Additional symptoms included weight loss of 4 kgs, shortness of breath, and enlarged right cervical lymph nodes.

The patient was a construction worker by occupation. The patient also complained of pain in his right arm which was of dragging in character, continuous and non-progressive. The patient was evaluated for Tuberculosis, and an FNAC of the enlarged lymph nodes was also done (Considering the site of involvement, dragging pain in the right arm and a history of chronic consumption of cigarettes.  ) which depicted Chronic Granulomatous Disease. 

After CBNAAT, the diagnosis of Koch's disease was confirmed and the patient was started on Anti Tubercular therapy. 

This particular case imparted the significance of constructing provisional diagnosis such that priority is given to the more common diseases. 

2022-2023

During my third year of medical school, I had the opportunity to understand the intricacies of through history taking, meticulous physical examinations, intricate literature reviews most significantly, patient follow-ups. 

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The following case was of a 56-year-old male, with a history of carcinoma of the bladder and Diabetes mellitus type 2 who had presented to the hospital for a follow -up.  

https://rishikakolotimedlog.blogspot.com/2022/09/56-year-old-male-with-type-2-diabeties.html

The patient had a history of high-grade urothelial bladder carcinoma, with no family history of any malignancy, which was excised. During the discussion of this patient, very interesting facts were uncovered. 

We learnt evidence suggesting that the patient was most likely prescribed pioglitazone as a therapeutic intervention for diabetes mellitus type 2. It was postulated that this medication potentially contributes to the development of bladder carcinoma.  

Not only this,  we were able to compare the efficacy of Anti-diabetic medication and do a cost-benefit analysis for the patient, giving him a treatment which was not only affordable but also effective. 

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The next patient, I would like to explain was one of the first of our many PAJR patients also a case of neurodegeneration with unknown aetiology.  

This is the report of a 51-year-old man, who complained of swelling in the left foot from the past three years, progressive loss of sensation in the left foot from the past 3 years and an ulcer in the dorsum of the left foot from the past 11 months. 

The case presentation and discussion can be seen in the following link: 

https://rishikakolotimedlog.blogspot.com/2022/09/51-year-old-male-with-swelling-and-loss.html

On history taking and examination, we found that the patient had an equine gait due to his foot drop.

The initial question raised was to determine the specific nerve involvement. 

We were able to determine clinically after thorough discussion that the deep peroneal nerve and tibial nerve were involved. 

The subsequent question was towards identification of potential etiologies for the observed symptoms : 

The discussion explored various possibilities : 

"There was a history of trauma to the left foot - Could that have caused neurodegeneration? 

Could there be an infective pathology involved? Hansen's disease? 

Could there be a tumour involving the common peroneal nerve? "

The possibilities seemed endless. Prompting the need for necessary investigations. 

We did Split skin smears and ulcer smears to look for an infective pathology, but they were negative for Hansen's disease. 

A High-resolution Ultrasound study of the left leg raised suspicion of a nerve sheath tumour. 

Nerve conduction studies and MRI were done, which showed a swelling of the tibial, and common peroneal nerve. 

Nevertheless, due to financial constraints at the end of the patient, a complete evaluation of the cause of the disease was hindered. The patient was treated symptomatically. 

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The following case was of a long-distance patient seeking a second consultation with respect to his treatment options for his diagnosis of non-small cell carcinoma of the lung. 

https://rishikakolotimedlog.blogspot.com/2022/09/77-year-old-male-with-non-small-cell.html

After meticulous history taking, and summarising of the reports the patient had provided, a PAJR group was created to understand the patient's problems. 

And the discussion concluded that the patient was on the most appropriate treatment according to his age, comorbidities and clinical history. 

SWOT analysis of this particular patient : 

Strength : 

- There was enhanced problem-solving, as many doctors and medical students collaborated to discuss the treatment options after reviewing various articles. 

- Quality was ensured: due to the presence of many doctors there was a very good opportunity to minimise errors 

Weakness: 

- Time constraints: As developing of a report with meticulous history is a tedious task, given the diagnosis, the patient had to wait for the case to be presented in terms of a case report to multiple doctors. 

- The diagnosis was such that the patient was unable to be motivated to describe his daily routine in the PaJR group. 

Opportunity : 

- The patient had the opportunity to discuss treatment options with multiple doctors and medical students who were able to review data. 

Threat 

- a threat to this approach includes: hesitancy in sharing data with multiple people at once 

- Accidental sharing of sensitive information, The threats were avoided by means of prior communication with the patient. 

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While i belive that this article represents the very beginning of my journey , I dervive great satisfaction in reflecting upon previous cases and the progress I have attained. 

Hope you enjoyed reading the following article  . 

Regards 

Rishika