112 Rishika Koloti : Skill Evaluation for June 2021

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



Q1.Go through one question of 10 students given in the following link -list of formative and summative assessments of the following students and give a peer review of the quantitative marking and the qualitative insights on what was good or bad in the chosen blog 

Ans 1. - Question that was chosen by me  -Question 1-PULMONOLOGY

Quantitative marking - 9/10 
Qualitative Insights - 

The evolution of symptomatology is described beautifully with the help of a diagram that makes it very easy to comprehend when viewed especially for visual learners 
Each intervention described for the particular patient has been given in a simple and legible manner.
 The mechanism of action is well described for each intervention 
.. 

Quantitative marking - 6/10
Qualitative marking -The document presented is not organized which makes it difficult for the reader to understand the beginning and the end of each sub Question. 
The symptomatology that has been mentioned here is difficult to comprehend. The mechanism of action for each intervention used for a particular patient is very well explained and in a language that is easy to understand. The Causes for current exaberation is explained well but could be enhanced by making the language continuous and adding the pathogens in a listed format
sub-question 4 - stating if the ATT could have affected the lungs is well reasoned. 
sub-question 5 - explaining the electrolyte disturbance is appropriate but could have been listed.

Quantitative marking -10/10
Qualitative marking - 
The overall look of this document pulls you to read each word, and the document is well organized the further enhances the readability. 
sub-question 1- has been explained in a beautiful diagram in chronological order which is easy to comprehend.
sub-question 2- explains the mechanism of action of each intervention in an easy language 
sub-question 3- is comprehensive 
sub-question 4 - is very well reasoned and easy to understand 
subquestion 5 - the causes of electrolyte imbalance are explained in-depth and each cause has been explained in an easy language 

Qualitative marking-7/10
Quantitative marking - 
the symptomatology in the given patient is not listed well that makes the document difficult to understand without giving it a second read, a diagrammatic representation would erase the problem 
the mechanism of action of each intervention is explained in an easy-to-understand language. 
subquestion 3, 4, and 5- are to the point and comprehensive.


Quantitative marking - 10/10
Qualitative insights - 
The entire document is very well-formatted, the organization of the data makes it very easy to look through. 
Symptomatology has been given in chronological order.
mechanism of action of each intervention has been listed well, the indications are easy to comprehend,
subquestions 3, 4,5 are listed very well.

 Quantitative marking -6/10
Qualitative marking - 
the symptomatology has not been listed in chronological order thus when one reads the document it becomes difficult to remember which symptom was seen by the patient at what time. 
The mechanism of action for each intervention could have been explained in depth 
subquestion 3- explanation of exacerbation has been depicted with a very simple diagram that explains the content in detail 


Quantitative marking-10/10
qualitative insights - 
the symptomatology has been explained in a chronological manner, the literature has been supported with the help of various diagrams that appeal to the reader 
each pharmacological intervention has supporting literature that would explain to any user how a particular drug would act, this is a very good example of evidence-based learning. 

the flow charts for each answer make it easier to comprehend,


Quantitative marking -9/10
Qualitative marking - 
The symptomatology is in chronological order and well listed, the anatomical representation is done with the help of diagrams that make it easier to understand.
self-drawn flow charts have explained the entire cause beautifully 
the interventions used have been classified very well and are easier to retain in the memory because of the clear listing of the particular answer 
subquestion 3,4,5 have been explained in depth with appropriate documentation 

Quantitative marking -7/10
qualitative marking - the document is well listed but could have been enhanced with the help of diagrams. the content of the document is explained well in a language that is easy to understand. the readability of the document could have been increased 


Link -10 - 

Quantitative marking - 10/10
Qualitative marking - 
the symptomatology has been very well explained with the help of a hand-drawn diagram, the etiology is very well supported with the help of a flowchart that appeals to the reader 
each subquestion has been made visible which enhances the readability of the document 
Each pharmacological intervention has been explained in-depth with comprehensive language

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. 

This is the E-log with relevant clinical images .


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

Link1 multisystem- Multisystem disease
Completeness of the following case presentation
 this case is complete in all factors
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
Icterus that was mentioned in the particular case has been supported with clinical images. 

The investigations of the particular patient are listed and they support the provisional diagnosis the changes in the patient's status and uncertainties around the diagnosis have been provided. 
Updates, on each day, have been mentioned very well and the changes in the treatment plan have been mentioned. 

CORRECTNESS - the data listed is correct

ABILITY TO PROVIDE USEFUL LEADS ON THE PARTICULAR CASE - 
the leads around hepatic encephalopathy as a post covid complications have the following articles which could have been included in the presentation of the particular case. 



COMPLETENESS - the e log has the history of the patient listed well and is complete as the symptoms and signs have been listed well. The case is supported well with clinical images and laboratory investigations, all in all, the log explains a story. 
the patient could be followed up and the treatment for the neurological defect could have been mentioned that would make the entire document complete. the mentioning of various reflexes as seen in link-evaluation 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- the investigations are correct

Ability to provide useful leads - useful leads have not been provided, a few leads that could have been included are- the MRI in this patient is compared to a normal MRI, clinical presentation of an epidural abscess.

COMPLETENESS - the e - log feels 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 


COMPLETENESS - the e-log is complete in all aspects, 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 is correct 

Ability to provide useful leads - leads on similar case presentations would have been great in order to understand and compare the atrial fibrillation due to hyperthyroidism 


Completeness- The case feels incomplete as there have been no updates after 23 June, and there is no discharge summary. 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 given correctly 

Ability to provide useful leads - leads around this case have not been provided a case presentation similar to this one would have been great to compare the clinical findings and the diagnosis. 

Question 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. 


 Problem list - 
  1. Low-grade backache 
  2. vomiting episodes  and loose stools 
  3. blood-tinged urine 
  4. polyuria , polydypsia ,noctunuria  
  5. burning micturation 
  6. lost apetite 
  7. Temperature - 100.5degree celcius 
  8. respiratory rate -24cpm- higher than normal 
  9. abdomen schaphoid 
  10. icterus present 
  11. Creatinine levels in the urine - 0.6 mg/dl which is lower than the normal range 
  12. SOdium level 132 mEq/L in the urine which is lower than the normal range. 
  13. ABG  shows PCO2- 17.4 mmHg which is lower than the normal range and PO2 - 119mmHG which is higher than the normal Range, PH - 7.26 that is acidic 
  14. Hemogram - MCV, and MCHC of the patient are lower than the normal range while the MCHC is higher than the normal range. The patient also presents with increased RBC count 
  15. Prothrombin time is increased -24 seconds 
  16. ketone bodies are present in the urine that indicates -DIABETIC KETOACIDOSIS  
  17. glycated hemoglobin is 6.6percent which is higher than the normal range 
  18. serum iron is increased is 150, while serum ferritin is .1500
  19. T3 and T4 are both reduced 
  20. The urine is slightly acidic, contains excessive albumin, and an increased level of sugar 
  21. C-Reactive proteins are elevated -2.4mg/dl
  22. APTT test has a higher value than the normal range 
  23. Right renal calculus 
  24. Right mild hydroureteronephrosis 
  25. COVID -19 antibodies are positive 
  26. Total bilirubin, Direct Bilirubin-HYPERBILIRUBINEMIA, Liver enzymes are normal
  27. Total serum proteins are low
  28. not responding to visual stimuli and acute retention of urine Bizzare starey looks- ABSENCE SEIZURES? 
  29. no passing of stools since 2 days - 
  30. Retention of urine
  31. Hepatic encephalopathy, multisystem inflammatory failure (post covid)
Diagnostic And therapeutic uncertainty - 

THE TREATMENT FOR THIS PATIENT INCLUDED -  
I. DIABETES KETOACIDOSIS 
the patient was started on Insulin therapy and IV fluids were given to the patient, on the second day of admission, the diabetic ketoacidosis was resolved. 

the diagnostic tests are done for coming to a conclusion that the patient had diabetic ketoacidosis was -
  • checking the presence of ketone bodies in the urine - this test came positive. 
  • estimating the value of glycated hemoglobin in the patient - which was 6.6percent of the total hemoglobin -which confirms the presence of elevated blood sugar from the past 3 months 
TESTS for checking the presence of ketone bodies in the urine - 
normally the presence of ketone in the blood is negligible, due to a balance between the carbohydrates and fats in the body, but in metabolic disorders like diabetes mellitus, in conditions like starvation, excessive amounts of carbohydrates are converted to ketone bodies as the body uses ketone bodies as fuel - and this causes increased levels of ketone bodies in the blood. the blood is then filtered out by the kidney, and the ketone bodies pass through the glomerular membrane causing the presence of ketone bodies in the urine which is checked by ROTHERA's test qualitatively. 

Rothera's test may be false positive if the particular patient has had exposure to Antihypertensive drugs like captopril or Free sulfhydryl groups 

But in this patient, as he presented with polydipsia, polyuria, and nocturia, with ELEVATED levels of glycated HB, the conclusion that the patient has Diabetic ketoacidosis is correct. 


TREATMENT  for DIABETIC KETOACIDOSIS - INSULIN THERAPY - 
in patients with diabetes mellitus type 2, the uptake of glucose from the blood is not efficient as a result, even though there is excess glucose the body cells do not get to use it, in such patients insulin therapy is done this allows the uptake of glucose from the bloodstream into the adipose tissue and muscle cells by the action of GLUT 2- receptors which are insulin-dependent. 

LINKS -

II.RETENTION OF URINE - 

treatment for prolonged retention of urine that does not respond to medication is catheterization - 
this allows a reduction in pressure in the patient's urinary bladder, which eventually prevents failure of the kidneys. it acts as a supportive measure till the patient regains the ability to micturate. 

this treatment also allowed us to check the color of the urine, which directed the treatment plan. 

III.RETENTION OF STOOLS - 

TREATMENT - supportive treatment with lactulose was given , this treatment 

  • lactulose is useful as it prevents portosystemic encephalopathy acts as a laxative and relieves chronic constipation. 
  • uncertainty - may cause hyperglycemia in patients with diabetes mellitus, may induce lithium toxicity in psychiatry patients. 
  • LINKS - Supportive therapy with lactulose
IV. HEPATIC ENCEPHALOPATHY, MULTISYSTEM INFLAMMATORY FAILURE (POST COVID )

DIAGNOSIS - 
  1. checking for the presence of covid antibodies - specificity of the test - https://www.cdc.gov/coronavirus/2019-ncov/lab/serology-testing.html





Problem list - 
  1. Known case of tuberculosis infection, loss of consciousness in the patient, generalised weakness, and myalgia 
  2. the tone of the lower limbs bilaterally increased 
  3. reflexes reduced 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 in this patient which is reduced as 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 
Diagnostic and therapeutic uncertainty around the patient - Initially it was thought that the patient is suffering from cervical myelopathy but with the help of the MRI, it was known that the patient had a rapidly progressing quadriparesis

The literature surrounding the diagnosis - 



Problem List - 
  1. Altered sensorium 
  2. morning lethargy 
  3. pedal edema with anasarca 
  4. history of hypertension 
  5. known case of chronic kidney disease 
  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 percent which is much less than the normal range 
  9. in the 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, Grade II -III Renal parenchymal disorder
Diagnosis- Renal Parenchymal Disorder 

treatment - hemodialysis.

The literature surrounding the diagnosis - Clinical presentation for comparison with said patient

Link 4 - CVS case

Problem List -
  1. abdominal distension 
  2. shortness of breath 
  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 



Link 5 - ABDOMINAL CASE

Problem list - 
  1. pedal edema 
  2. decreased urine output, burning micturition  
  3. known case of DM type 2, acute kidney injury secondary to urosepsis 
  4. High Blood Pressure - 170-110 mmHg
  5. Pulse rate is high - 111 beats per minute 
  6. on complete urine examination - albumin levels were present 
  7. Ultrasound Examination - Right kidney had grade I Renal parenchymal disease, Left kidney had Grade II Renal parenchymal Disease 
  8. Raised serum creatinine - 3.4 mg/dl
  9. Raised Blood Urea- 65 mg/dl
  10. Serum eleclytes - Potassium level raisedd - 5.3 milli equivalents  /L


Question 5 - Please reflect on and share your telemedical learning experiences from the hospital as well as the community patients over the last month especially when you were E-logging 

Answer - My experience of telemedicine has been great, I was really disheartened when the lockdown began as I thought I would completely miss out on all clinical aspects of training, communication with the patient, understanding the disease, how each disease shows different signs and symptoms in each patient 

with E logging and integrating the learnings with my current subjects, pharmacology, pathology, and microbiology I have understood the why's of the disease and its presentation I have understood why a particular drug is prescribed and how it helps the patient. although I understand that there is absolutely no replacement for hospital learning, this is a close second and I am grateful for this opportunity. 

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