General Medicine monthly assignment(June 2021) by Riddhi Bhalla 3rd semester (Roll no: 111)
GENERAL MEDICINE Monthly assignment for June 2021
For link to questions for the assignment click here.
The theme for this assignment is "Scholarship of integration in medical education and research" in keeping with this theme I have tried to include my knowledge from multiple streams into the following answers. Being a 3rd semester student I found my understanding to be limited in many cases so I have provided links for further reading incase you would like to do so. Any criticism is much appreciated to better myself and my understanding.
Question 1] Peer review of one particular answer of 10 randomly selected students.
Answer1] I have chosen the following case to review: Epigastric pain in 25 year old male
For link to case study and related questions click here
For the purpose of review I have made a sample answer myself against which I will be comparing and marking 10 random answers.
My answer:
The patient has presented with acute epigastric pain, not radiating backwards. Abdomen is tender. He is non coherent due to heavy alcohol intake. Patient has history of abusing alcohol(as reported in personal history). Lab reports have shown elevated LFTs and elevated serum amylase and lipase.
Most probable diagnosis would be ALCOHOLIC LIVER DISEASE and ACUTE PANCREATITIS.
A. The reason for SOB ie. dyspnea in patient is likely due to multiorgan failure because of acinar cell death. Toxic cytokines and IL-1,2,6 are being circulated. This has produced inflammation of the pleura and pleural effusion has taken place thus causing Dyspnea
B. Hyperglycemia has been caused either by hyperglucagonemia secondary to stress or because of destruction of Beta pancreatic islets. Both of these antagonists to insulin activity have produced hyperglycemia.
C.Damage to the liver causes intrahepatic enzymes like AST, ALT, 5' Gamma nucleotidase to elevated in the serum. Direct and total bilirubin are elevated suggestive of hepatocyte destruction. One important thing to be noted however is that albumin level is normal which tells us that synthetic function of liver is not that easily impaired.
Biomarkers for alcoholic liver disease are as follows:
1. Normally AST is more than ALT levels but in ALD the AST:ALT ratio increases to 2. It is usually a confirmation for this diagnosis. ALT activity is reduced due to B6 deficiency in chronic alcoholics.
2. Elevated bilirubin indicates loss of detoxification and conjugation function of the liver.
3. In extreme cases steatorrhea is noted due to poor lipid metabolism because of impaired liver function.
4. Elevated LFT are indicative of metabolic syndrome or even predisposing to it. Elevated LDL(Like in familial hypercholesterolemia) has adverse effect on hepatocyte function and may result in LFTs even if patient is not an alcoholic.
This information has been taken from Lippincott textbook of Biochemistry. Additional information maybe found in this hepatology journal. Click here.
D. Treatment plan has zofer, Pan and Tramadol. So line of treatment is symptomatic and is aimed at reducing pain, bringing down fever and assessing patient for denovo diabetes mellitus 2.
Now keeping the above in mind I will be reviewing 10 random answers provided in this link here. There were about 180 responses to choose from and the answers have been randomly selected. I will share my opinion as well as a score out of 5.
Response 1 here: Reason for dyspnea is clearly mentioned. Specific biomarkers have been mentioned clearly. Answer to WHY a particular marker is elevated is not clear. Line of treatment is mentioned well [3/5]
Response 2 here: In my view this answer is the most complete and comprehensive in all responses reviewed by me. [3.5/5]
Response 3 here: Answer is vague in terms of the reason for elevated LFTs. Biomarkers are mentioned clearly but reasons have not been outlined. Line of treatment is well written[3.0/5]
Response 4 here: Reason for dyspnea is clearly mentioned. Statistics have been enumerated clearly but reason for elevation of LFTs have not been highlighted. Line of treatment is written well[3/5]
Response 5 here: Answer contains all important points but language of the answer makes it a little cumbersome to comprehend.[2.5/5]
Response 6 here: Biomarkers have been mentioned but reasons for elevation w.r.t loss of specific liver functions has not been mentioned.[3/5]
Response 7 here: Similar to previous responses the biomarkers have not been elaborated. Reason for dyspnea and hyperglycemia is well written.[3/5]
Response 8 here: Answer is vague in terms of the reason for elevated LFTs. Biomarkers are mentioned clearly but reasons have not been outlined.[2.5/5]
Response 9 here: Specific biomarkers have been mentioned clearly. Answer to WHY a particular marker is elevated is not clear. [2/5]
Response 10 here: Statistics have been enumerated clearly but reason for elevation have not been highlighted. More links for references and reading have been cited.
**General statement for all observations: Answer to LFTs has been quoted from a common source directly while case specific answers were answered more originally and logically.
Question 2] ELOG of a patient, related case discussion
Answer2] I have made an elog of a patient who was initially thought to have Parkinsonism but was later found to have been effected by Left frontal lobe infarction in ACA territory along with arteriosclerotic hemiparkinsonism.
This is the link to my ELOG. https://riddhibhalla25.blogspot.com/2021/06/70-year-old-presenting-with-loss-of.html
Question 3]Peer review on completeness, accuracy and usefulness of collected patient data
Answer 3] I have been provided with 4 case studies. I will be reviewing them basis the above mentioned criteria.
CASE 1: CNS case https://pallavi191.blogspot.com/2021/06/gm-cases.html?m=1
POSITIVES
Case sheet is novel. Ethically sound, as all patient data has been sufficiently deidentified. Personal history is very detailed. Diagnostic reports and images are clear and are explained too. Provisional diagnosis was correctly made. Discharge summary also includes future care and treatment plan. The MRI scan done to confirm cervical myelopathy rules out uncertainties.
NEGATIVES
I could not find any factors to improve upon in this case report.
CASE 2: Renal case https://61tejarshini.blogspot.com/2021/06/general-medicine-case-discussion.html?m=1
POSITIVES
Case sheet is novel. Ethically sound, as all patient data has been sufficiently deidentified. Title of case is appropriate and describes the case sheet well. Treatment is well charted. Diagnostic tests are clear and appropriate.
NEGATIVES
Personal history is absent. No mention of addictions is there. In diagnosing CKD alcohol and tobacco use must be charted but is absent. In diagnostic section a line about conclusion of individual reports when abnormal would make report easier to read and rule out differentials.
CASE 3: CVS https://60shirisha.blogspot.com/2021/06/medicine-case-discussion_14.html?m=1
POSITIVES
Case sheet is novel. Ethically sound, as all patient data has been sufficiently deidentified. Title of case is appropriate and describes the case sheet well. Treatment history is abundantly clear.
Video evidence has been attached for 2D ECHO making the diagnostic section of this report very satisfactory.
Biomarker tests have been conducted ( C-reactive protein, Troponin) to rule out recent cardiac arrests and reason for atrial fibrillation is clearly pre existing condition of hypothyroidism.
NEGATIVES
Report is very comprehensive and I do not find any gaps in it.
CASE 4: Abdomen https://casescape.blogspot.com/2021/06/acute-kidney-injury-secondary-to.html?m=1
POSITIVES
Case sheet is novel. Ethically sound, as all patient data has been sufficiently deidentified. Title of case is appropriate and describes the case sheet well. History of chief complaints and past illness is clear.
Diagnostic reports and imaging is the most well done section on the report.
Treatment has been charted well and daywise treatment plan has been provided.
Provisional diagnosis was proven right by diagnostic tests.
NEGATIVES
No images are present for demonstration of edema as written about in general examination.
Treatment history of patient is absent. No mention of any previous medication thus we do not know if any treatment has precipitated urosepsis in the patient or if the condition is purely due to natural causes.
Personal history could be more elaborate.
GENERAL STATEMENT FOR ALL REPORTS: Non pharmaceutical interventions should also be suggested and mentioned in case reports.
Question 4] List patient problems, solutions in each of the cases provided. Elaborate on efficacy and effectiveness of treatment provided.
Answer 4] I found making the lists manually more convenient so I have attached images of my notes under every case.
CASE 1: CNS case https://pallavi191.blogspot.com/2021/06/gm-cases.html?m=1
Efficacy: HRZE stands for isoniazid, rifampicin, pyrazinamide and ethambutol. It is given for 1 to 2 months to eliminate the vast majority of the population and to prevent resistance. It is followed by a 2 to 7 month 2-drug continuation phase of isoniazid with rifampicin or thiacetazone to kill the rest of the bacterial population. It is found to be the most efficient and cost effective treatment with least cases of recurring infection. See this paper on efficacy of different regimens for TB for more
CASE 2: CVS https://60shirisha.blogspot.com/2021/06/medicine-case-discussion_14.html?m=1
CASE 3: Renal case https://61tejarshini.blogspot.com/2021/06/general-medicine-case-discussion.html?m=1
CASE 4: Abdomen https://casescape.blogspot.com/2021/06/acute-kidney-injury-secondary-to.html?m=1
Efficacy: The overall effectiveness in ofloxacin was 14 out of 15 and 12 of 15 in the norfloxacin group of antibiotics.
Ofloxacin 200mg once daily was as effective as norfloxacin 400mg twice daily in this trial that I looked up to check efficacy of treatment More on efficacy of noroflax here. Ciprofloxacin could also have been used as it is seen to have produced less nausea and vomiting in patients. More on ciprofloxacin here
Question 5] Log your experience on the past month's experience on telemedicine.
Answer 5]From the beginning of the lockdown which trapped us all in our houses, I think I have never felt a wider variety of emotions in my life. Initially being at home was a breath of fresh air, we got to be in the comfort of our homes, with our parents and exams seemed like a distant nightmare.
But as the period kept getting extended it quickly took a turn for the worse. The cases kept increasing, news became grim and the fear of being incompetent "zoom" doctors was looming above our heads. I was very unsure of online clinical postings initially, having heard the importance of a hands on experience from doctors and our seniors. But at the end of one month I have changed my tune.
Getting exposure to the ICU, general wards, seeing 10 different patients in a span of just 2 hours, each with their own unique set of symptoms, has motivated me once more to put my all into my studies. Reading endlessly had become monotonous and I had honestly lost sight of why I had chosen this line initially. For me telemedicine has been a much needed light at the end of a dark tunnel
We had 4 sessions of 2 hours each. Each session covered approximately 8 to 10 patients. I would want to talk about a few very memorable cases that I came across.
The case of hepatic encephalopathy in an 18 year old boy following a possible asymptomatic COVID-19 infection. What was so memorable you ask? Well the patient was comatose for 4 days and on the 5th day he was miraculously walking, eating and resumed normal life shortly after. Seeing such a dramatic improvement in such a grave case impressed upon me the wonder of modern medicine.
The case of rat poisoning in a middle aged woman. This was on the other end of the spectrum. The lady presented with excessive bleeding from oral cavity, her liver had given up almost completely and extreme shortness of breath, following a yellow phosphorus poisoning. Unfortunately she passed away within a few hours. This made me realize how important timely treatment can be. It also was a reminder that something I read about today, can actually save a life when I start practicing as a doctor.
I also got the chance to work under an intern Sameera ma'am who helped me make my first ever ELOG of an actual patient! I got a case of vascular hemiparkinsonism as a result of frontal lobe infarction in ACA territory. I can rattle of all the details of the patient even if someone woke me up from my deepest sleep and I guess that's how everyone feels about their first "real case". I was very excited about this case and definitely learned a lot from it. Just the fact that our diagnosis and treatment is actually making a difference in a real person was surreal to me.
While I enjoy these online sessions, it makes me want to start offline postings even sooner. It would be even more interesting and I'll certainly learn even more once I get to examine a patient myself. Hopefully we all get that chance soon.
END OF ASSIGNMENT
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