112 Rishika Koloti -Medicine Blended Assignment - July 2021

This blog is an assignment that was given to us for the evaluation of our competencies that were observed in the last month. 

This month's assignment is focused on renal failure patients.

Link to the questionnaire - Medicine paper for July 2021 bimonthly blended assessment

Question 1 - Please go through one student's entire answer paper from this link- 2019 Batch Medicine department online formative and summative assessment for June 2021, the one who is closest to your own roll number, and share your peer review of each answer with your qualitative insights into what was good or bad about the answer.

ANSWER 1- 

The link chosen by me for peer review is -Riddhi Bhalla, roll number -111

Question 1: This question has been explained very well, for the purpose of review, the candidate has answered the question herself, and compared her answer to the remaining 10 answers. This is a very good idea, it provides us with the information and presentation that the student was looking for when she was reviewing the answers. Also, it acts as a control for the answers she was reviewing. Each answer that was reviewed has been graded appropriately, and the qualitative reviews for the quantitative marking have been well explained. 

Question 2- The E-log that was linked, is complete and very informative and in my opinion one of the best I have seen till now. It also includes a section on the discussion of the case that helps to enhance the understanding of the case. Relevant deidentified clinical images are present. The case sheet covers all aspects required to understand the patient's condition. The Case sheet is comprehensive and complete. Resources for understanding the case have been linked. The detail in which the case is linked is unmatched. 

Question 3 -The question was on reviewing the completeness, accuracy, and usefulness of the collected patient data, The answer has been written appropriately with well-demarcated sections of positives and negatives for each case. Sites for improvement have been mentioned. 

Question 4 - The problem list and treatment list for each case have been listed well. The efficacy of each treatment has been explained well and the resources used to understanding the treatment are listed. This is a complete answer.

Question 5- The  Student has explained her experience with telemedicine. It is an accurate representation of all emotions a medical student has faced during the period of lockdown. The concerns, the nervousness one would face on knowing how much one is missing out on clinical aspects of training is relatable on every level. 

All in all this assignment is complete, comprehensive, and accurate.  

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.

Answer 2- 19-Year-old female with Pancytopenia

Discussion of the above-linked case - 

Before admission, the patient presented with complaints of heavy menstrual bleeding, shortness of breath - she had difficulty in breathing on lying down, had a severe attack of breathlessness on the day of admission. She had hypothyroidism since childhood and was on thyronorm for the past 9 years. The patient presented with hyperpigmentation of the knuckles and mild purpura. Her thyroid gland was enlarged. All the clinical images are linked above. 

ON examinations, we found out that the patient had massive splenomegaly, pancytopenia. 

The slides of a bone marrow examination that were done 7 years back on the patient was re-examined and we found out that the patient had Myeloid suppression and erythroid hyperplasia - which was suggestive of dual deficiency anemia

Treatment that was given included -
Tab. Thyronorm, Inj Vitcofol, Tab, Regestrone, Tab Orofer.

The patient was discharged on request as she had upcoming exams. the Etiology, treatment, and management of the patient were explained to the patient and her attendees, and she was advised to return for a follow-up. 

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.

LINK 1 - Patient with AKI secondary to UTI, lower back pain

COMPLETENESS: 

• The investigations have been mentioned in detail in chronological order.
•  In certain investigations, the units have not been mentioned. 
• Otherwise, the E-log is complete and gives us an idea of the disease. 

ABILITY TO PROVIDE USEFUL LEADS TO ANALYSE THE DIAGNOSTIC AND THERAPEUTIC UNCERTAINITIES; Literature surrounding the case sheet can be added. 

LINK 2- Patient with Acute renal Failure, Spondolytis, Hyperuricemia

COMPLETENESS- 

• History of Presenting illness has been described well, it gives clarity over the presentation of the disease. 
• Personal History and Family history are missing.
• All investigations have been clearly mentioned, and provide a reason for the diagnosis. 

ABILITY TO PROVIDE USEFUL LEADS - Leads can be added 

LINK 3-49 Year Old Female with generalized weakness and vomiting

COMPLETENESS- 

• The Elog is detailed. it contains a very good history summarizing the life events of the patient. 
• All aspects of the examination are complete. 
• The abnormal findings are underlined, which helps the person reading the report in understanding what is wrong. 
• Each day has been logged in detail. 
• I don't find any negatives in this case sheet 

ABILITY TO PROVIDE USEFUL LEADS - leads can be added 

LINK 4- here

COMPLETENESS 

• The elog is complete 
• It contains a detailed history summarising the life events of the patient and the progression to the disease. Though personal history should be added, 
• Clinical images have been presented properly. 
• Treatment and investigations have been listed day-wise. 
• This is a complete case sheet 

ABILITY TO PROVIDE USEFUL LEADS - Leads can be added. 

LINK 5- here

COMPLETENESS- 

• The data that has been provided is complete. 
• This case sheet is accurate information from day 1 till the day of discharge. 
• The history has been presented well 
• Clinical imaging has been done
• Investigations and treatment have been mentioned day wise 
• This is a complete case sheet 

LEADS- Leads can be provided 

LINK 6- here

• This e-Log is detailed 
• The history has been well described that makes the E-log very comprehensive 
• Investigations and treatment has been liked day-wise
• Detailed clinical imaging has been done
• Reference to  normal imaging has been provided 
• All in all it is a complete E-log 

Link 7 - here

• The E-log follows the format of the case sheet 
• leads are present 

LINK- 8 here

• The E-log is complete and follows the standard format of the case sheet
• addition of the course in the hospital has been made that makes the case sheet even more comprehensive. 
• clinical imaging has been done appropriately
• each complaint has been mentioned in detail 
• all investigations have been listed

LINK -9 here

• This e-log is comprehensive and complete 
• it contains a detailed depiction of the treatment plan day wise 
• clinical imaging has been done properly 
• investigations have been added day wise 

LINK 10 - here

• The standard format of a case sheet has been followed. 
• relevant clinical images are present 
• Investigations are well listed 
• the literature surrounding the case can be  provided 
• treatment is well listed according to each day 

LINK 11- here

• This case follows the standard format of a case sheet 
• the history has been well listed 
• relevant deidentified investigations have been listed 
• A summary has been provided that makes the case comprehensive 

Question 4  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 the literature around sensitivity and specificity of the diagnostic interventions mentioned and the same around the efficacy of the therapeutic interventions mentioned for each patient.

Link 1- Patient with AKI secondary to UTI, with Lower back pain\

Problem List - 

1. Lower abdominal Pain 
2. Burning Micturation decreased urine output 
3. Lower backache 
4. Fever
5. SOB
6. UTI - polymicrobial flora 
7. AKI secondary to UTI  associated with DM type 2 
8. Degenerative Osteoporotic CHanges seen in the vertebral discs
9. Muscle Spasms 

Treatment and efficacy - 

1. Salt restriction - This was done in order to prevent excess stress on the Kidneys 
2. INJ. TAZAR -Antibiotic for UTI
3. INJ. Pantop- Reduces acid in the stomach 
4. Inj. Thiamine -
5. Tab. PCM - paracetamol for the fever
6. TabMyoril - Muscle relaxant 
7. Tab Shelcal - prevents osteoporosis

Rationale - The provision of thiamine in patients with AKI may reduce the severity of sepsis-related AKI. To read more click on this link - THIAMINE AS A RENAL PROTECTIVE AGENT IN SEPTIC SHOCK. A SECONDARY ANALYSIS OF A RANDOMISED TRIAL, DOUBLE-BLIND, PLACEBO-CONTROLLED TRIAL

LINK 2 - here

Problem list - 

1. Pedal Edema 
2. Hyperuricemia 
3. Dyspnoea
4. Renal Failure 
5. multifocal spondolytis 

Treatment  -

1. Inj Tazar-Antibiotic 
2. Inj Lasix -for treatment of edema
3. Nebulisation Salbutamol
4. Inj Pantop
5. Tab PCM
6. Inj Piptaz
7. Syrup mucaine gel 
8. Tab Febuxostat
9. Inj Optineuron

LINK 3 - 49-Year-old female with generalized weakness and vomiting

PROBLEM LIST -

1.  Acidosis 
2. Hb - lower than normal 
3. Anisopokilocytosis with macrocytes, macrocytes, maco ovalocytes, and a few teardrop cells 
4. Elevated serum creatinine and blood urea 
5. plasma cell dyscrasia, multiple myeloma 
6. Bilateral grade 2 Renal Parenchymal disease 

TREATMENT  - 

1. Tab. PAN
2. Fluid and salt restriction 
3. Tab Zoffer
4. Tab Nodiosis 
5. Iron supplementation 
6. INJ. Optineuron 

Link 4 - here

Problem list -

1. Diabetic ketoacidosis 
2. Electrolyte imbalance 
3. altered sensorium 
4. bed sores
5.  AKI
6. Pyelonephritis
7. UTI- E.Coli
8. Bedsore - acinetobacter growth

Treatment  -

1. Inj Norad
2. Inj. Piptaz
3. Inj. Dopamine 
4. Inj Hai 
5. Inj Clexane

Link 5 - here

PROBLEM LIST 

1. Infective endocarditis secondary to UTI klebsiella pneumonia infection 
2. Acute infarcts in bilateral cerebral and cerebellar hemispheres
3. Ulcer over the sole of the right leg 
4. CKD 

TREATMENT AND EFFICACY

1. Inj Monnocef
2. Inj Vancomycin 
3. Inj Pan 
4. Inj, THiamine 
5. Inj. Augementin
6. TAb. Ecospirin 

links used by me for comparison of endocarditis with the said patient - here

this is a review of 2 cases of endocarditis.

Link 6 - here

Problem list - 

1. Bilateral Hydroureteronephrosis 
2. AKI secondary to urosepsis 
3. Diabetic Nephropathy 
4. Anemia 
5. Bedsores 

Treatment -

1. Inj. Pantop 
2. Inj Piptaz
3. Inj. Lasix 
4. Inj Optieuron 
5. Inj. Nedmol
6. Tab . Pcm 
7. Insulin Human actrapid 

Link 7- here

Problem List - 

1. Heart Failure with reduced ejection fraction secondary to CAD 
2. Chronic Renal Failure 
3. Bilateral grade 1 RPD
4. Mild Pleural effusion 
5. elevated serum glucose  
6. deranged Renal function test 

Treatment - 

1. Tab. Bisoprolol
2. Tab. Nitrohart 
3. Tan. Nicardia 
4. Tab. GLiciazide 
5. TAb. Nodiosis 
6. Cap. Gemsoline 
7. Tab . Ecospirin 

the literature surrounding the following case -

Heart Failure in Patients with Chronic Kidney Disease: A Systematic Integrative Review
 CITATION-

Liviu Segall, Ionut Nistor, Adrian Covic, "Heart Failure in Patients with Chronic Kidney Disease: A Systematic Integrative Review", BioMed Research International, vol. 2014, Article ID 937398, 21 pages, 2014. https://doi.org/10.1155/2014/937398

Patient, Problem: Adults with a primary diagnosis of CKD and HF
Intervention: HF treatment was defined as any formal means taken to improve the symptoms of heart failure
Comparison: 1439 Patients were compared, and 23 articles were hand-searched.
Outcomes: Control of fluid overload, use of beta-blockers and angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and optimization of dialysis appear to be the most important methods to treat patients with HF in CKD and ESRD patients

Link 8 - here

Problem List - 

1. Pedal Edema 
2. decreased urine output 
3. Vomiting 
4. loose motions 
5. right heart failure 
6. serum creatinine is elevated 
7. hypercapnia 

Treatment - 

1. hemodialysis 
2. fluid restriction 
3. Tab Pan 
4. Inj Lasix 
5. Thiamine Inj 

Link 9 - here

Problem list -

1. Alcoholic Hepatitis 
2. AKI secondary to Acute Gastroenteritis 
3. HF r EF secondary  to CAD 
4. Alcoholic and tobacco Dependence Syndrome  
5. Mallory Weiss tear Healing Phase - Gastroduedenitis 

Treatment - 

1. INJ - THiamine 
2. Inj Optineunon 
3. Inj Lasix 
4. Tab . Aldactone 

Link 10 -here

Problem List -

1. AKI secondary to urosepsis 
2. Hyperkalemia 
3. Anemia 
4. Renal Parenchymal disease 
5. Pedal edema 

Treatment -

1. Tab Nodiosis 
2. Tab . Orofer
3. Inj Lasix 
4. Inj - Magnexforte 
5. Tab  Ultracet 

 

Link 11 -here

Problem 

1. Acute PAncreatitis 
2. Raised serum creatinine levels 
3. Pedal edema, Scrotal, and penile edema  
4. AKI 

Treatment list 

1. iv fluids
2. IV Lasix
3. Tab Nodosis
4. IV PIPTAZ 4.5 Gms. BD
5. Iv 25%Dextrose. 100 ml BD

Question 5 - 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.

Answer - 

The past month has been one where I have learned the most with the help of E-logging cases. My classmates and I were assigned to interns, I have had the opportunity of working under  Dr. Chitra ma'am, who has not only been providing our group with a number of cases but also has been patient with our doubts. I can't wait to be back on campus to actually start clinical rotations.