"MY EXPERIENCES WITH GENERAL CELLULAR AND NEURAL CELLULAR PATHOLOGY IN A CASE BASED BLENDED LEARNING ECOSYSTEM'S CBBLE "

Greetings,

I am Riddhi Bhalla, a passionate medical student hailing from India. Through this blog, I invite you to join me in exploring a fascinating compilation of medical cases that have captured my attention. Guided by the wisdom and expertise of my esteemed mentors, I have diligently examined these cases to deepen my understanding of patient care during the early stages of my medical journey. 

Here, we will unravel the mysteries of clinical medicine, delve into the treatment approaches employed, and discover valuable lessons along the way. This here is quite literally the key to all my clinical experiences and learnings till date. Here's presenting all my cases, learnings and experiences in one place as a final year medical student in India. 

Welcome aboard, and prepare to immerse yourself in these intriguing narratives.

Warm regards,

Riddhi Bhalla

Case 1

Title: Managing Ankle Tuberculosis Osteomyelitis and Sural Nerve Neuralgia: A Challenging Patient Journey

Tap to view complete case report

As a medical student, I encountered a complex case involving ankle tuberculosis osteomyelitis and sural nerve neuralgia in a 20-year-old male farmer. This personal experience write-up aims to provide insights into the diagnostic challenges, treatment interventions, and the impact it had on the patient's daily life and overall well-being.

Onset of Symptoms and Initial Assessment:

In August 2022, a 20-year-old male farmer presented to our tertiary hospital with complaints of mild pain over the dorsum of his right foot. Initially, he managed the discomfort with over-the-counter painkillers, but the pain gradually intensified, accompanied by swelling. Recognizing the need for further evaluation, the patient sought medical attention.

Events prior to admission into our hospital :

A thorough examination and an MRI revealed ankle tuberculosis osteomyelitis affecting the talonavicular joint. In June 2022, an exploratory ankle arthrotomy was performed to drain the pus from the swelling and obtain a biopsy for definitive diagnosis. The procedure aimed to provide a foundation for appropriate treatment planning.

Anti-Tubercular Treatment and Persistent Symptoms:

Following the surgical intervention, the patient commenced an anti-tubercular treatment (ATT) regimen in July 2022. Despite multiple negative tuberculosis test results, the patient continued to experience persistent pain even after six months of treatment.

Daily Life Obstacles and Future Treatment Options:

The patient's persistent right ankle pain severely limited his capacity to carry out farming tasks, creating serious socioeconomic hardships for his family. The choice was taken to look into alternative therapy options once it was determined that the symptoms had only somewhat improved. Medication such as tramadol and paracetamol were prescribed to properly manage the pain.

Observations of Sensory Deficiencies and Numbness: Throughout the patient's journey, we saw that the right foot's dorsum and ankle joint had decreased sensation. The initial exploratory arthrotomy appears to have caused this loss of sensation and numbness, which may have been caused by incisional injury to the sural nerve, leading to loss of sensation. The neuralgia could also have been caused by the tuberculous osteomyelitis Or a combination of both surgery and infection. 

Consideration for Further Testing and Treatment:

Given the patient's clinical presentation, further diagnostic investigations such as sural nerve testing and steroidal injections were recommended to assess and address the nerve damage. However, the patient's limited understanding of the condition and his poor socioeconomic status prevented him from pursuing these options, despite their potential benefits in optimizing treatment outcomes.

Ongoing Follow-up and management: We created regular follow-up using a variety of communication channels, including telemedicine consultations and participation in PaJr groups, to guarantee full treatment and support. The patient currently reports minor pain, mostly felt in the morning, which tends to get better with exercise. Monitoring any potential decline in nerve function necessitates ongoing observation.

Conclusion: From a diagnostic and therapeutic perspective, managing this patient's ankle TB osteomyelitis and sural nerve neuralgia presented several difficulties. We sought to address the patient's physical and emotional well-being by providing compassionate care. Despite continued socioeconomic barriers to receiving some therapies, we are nevertheless optimistic about the patient's outlook and happy for the chance to be there for him at this time. 

The patient's PaJr group discussions are available here

Case 2

Title: A Journey of Diagnosis: Unraveling the Mystery of Loss of Speech and Neck Stiffness

Tap here to view complete case sheet

This case is close to my heart for several reasons. Primarily because it was perhaps the first time I played the role of an empath, a source of comfort to my patient and a true healer and not a mere physician. This experience heavily contributed to how I approach patients with debilitating conditions now. The spastic dysarthria case was in the ICU and will be a distinct case in my memory for a couple of reasons.

Now would be a good time to mention that I usually have a hard time connecting emotionally to my patients sometimes due to my language barrier. 

Like any other day Or patient I expected my interaction to be strictly about the case and rely on my telugu speaking counterparts for a deep dive into the patients personal history. 

What surprised me was that the patient and her daughter (the attender) were extremely patient with me and genuinely wanted to answer all my questions seeked answers for some of their own questions. I stayed in contact with the family in person on 3 to 4 consecutive days and once on call too. Each day she would ask me the same question about when she would regain her speech completely and everyday I would say soon and give her amole reassurance. 

When she was finally shifted out if the ICU into the general ward we had our final interaction where out of nowhere the patient started crying, this was perhaps due to a feeling of anxiety or hopelessness upon seeing so many budding doctors discuss her case while holding up terribly medical looking MRIs and CT scans (patient was from a rural area and understandably her lack of knowledge about these things added to her troubles) 

This was the first time since starting postings in the hospital since September of 2021 that a patient actively seeked comfort in me in the time of distress. 

It was a very new experience and perhaps my most memorable one till date where I experienced what most caregivers talk about all the time and that is disappointing patient outcomes in diseases with poor prognosis and what our role is in such situations. 

It made me truly want to find newer better treatment modalities and it was maybe the first time I fully understood why certain healthcare professionals are so enthusiastic about Research. 

Hopefully we learn how to deal with such situations better and come up with novel therapeutic strategies. 

Introduction:

In this captivating case, we delve into the intricate details of a 70-year-old woman who presented with the chief complaints of loss of speech and neck stiffness. Through the collaborative efforts of a dedicated medical team, we embark on a journey of clinical analysis to unravel the underlying cause of her symptoms and devise a tailored treatment plan.

Case Presentation:

The patient, a 70 year old woman, presented with abrupt onset neck stiffness and speech issues. She indicated that the symptoms had gotten worse over the previous two days, though she was unable to pinpoint the exact commencement. Her medical background showed a previously asymptomatic interval followed by right shoulder pain, which was conservatively treated seven years ago. She thereafter had weakness and giddiness, which resulted in a hypertension diagnosis five years ago. She had been taking TAB.ATENOLOL 25mg at first, but lately changed to TELMA-40 due to insufficient blood pressure management. She also felt pain in both lower limbs that had persisted for five years; it had been first treated with TAB.ACECLOFENAC and TAB.PREDNISOLONE-5mg but stopped two months prior.

Clinical Examination:

During the physical examination, signs of pallor were observed in the palpebral conjunctiva and palms. No other significant abnormalities were detected, including icterus, cyanosis, clubbing, lymphadenopathy, or edema. The vital signs indicated a blood pressure of 130/80 mmHg, a pulse rate of 105 beats per minute, a respiratory rate of 22 cycles per minute, and a normal temperature.

Systemic and Neurological Examination:

The abdominal examination revealed soft and tender findings without any masses or distension. The cardiovascular examination yielded normal cardiac sounds, with no murmurs or thrills. In the respiratory system, normal vesicular breath sounds were heard, and there were no chest wall deformities or abnormal findings on percussion, with no wheezes or crackles detected. The neurological examination showed the patient to be conscious and coherent, with normal motor reflexes. However, speech was sluggish and there were signs of cranial nerve involvement. Notably, the patient exhibited a slow, sluggish gait and difficulty maintaining balance while walking.

Investigations and Diagnosis:

The initial provisional diagnoses of Hypocalcemic Tetany and Parkinson's disease were considered. However, further investigations were conducted to confirm the underlying condition. An ECG and complete blood picture were ordered, revealing normochromic normocytic anemia and slight leucocytosis. Serum creatinine levels were elevated at 2.3mg/dl. A subsequent MRI revealed a large acute infarct in the left frontal lobe, in the anterior cerebral artery (ACA) territory. The MRI also indicated old infarcts in the right lentiform nucleus and corona radiata, as well as diffuse cerebral atrophy and chronic microvascular changes due to ischemia. Bilateral periventricular hyperintensities were also observed.

Based on these findings, the final diagnosis was made, revealing a left frontal lobe infarction within the ACA territory.

Treatment and Management:

The patient received a comprehensive treatment plan tailored to her specific condition. Initially, she was administered Inj OPTINEURON, Tab MIFENAC-MR, Tab PAN 40 mg, Tab FLUPERTINE, oint OMNIGEL, and Tab SHELCAL, among other medications. Further interventions included IFT Neck (Intermittent T cervical fraction) and GRBS monitoring. As the treatment progressed, modifications were made, and additional medications such as Tab Syndopa, Tab Clopit

Case 3

Title: Overcoming Cavernous Hemangioma

Tap here to view the case report

Each patient's path tells a different story of difficulties, optimism, and resiliency in the field of healthcare. This first-person narrative tells the tale of a 45-year-old woman who has a cavernous hemangioma. We want to convey her journey of diagnosis and treatment through this narrative. 

The Finding: At the base of our patient's neck, an apparently unimportant bulge first emerged six years ago. She didn't opt to go to the doctor because the swelling didn't seem to be painful at the time.

Painless to painful transformation: The swelling underwent a surprising transformation two months ago. Our patient was tormented day and night by the formerly painless presence.  

 Concerned, she sought solace in a hospital in Siliguri, where painkillers were prescribed, albeit their names now forgotten.

As days turned into weeks, the swelling grew in both size and intensity. Its unwelcome presence imposed physical limitations.

A New swelling:
Adding to the already arduous path, a fresh swelling emerged on her lower back. Though lacking the pain of its counterpart.

Path to Healing:
After thorough examination the medical team pieced together the diagnosis which was cavernous Hemangioma

 Recovery:
Embolization— A procedure designed to halt the progression of this hemangioma alleviating her pain, and restoring her quality of life.