90 Mutyapu Raghavendra

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Medicine Paper For July 2021 Bimonthly Blended Assessment


This is the link to Question paper: 


Question 1:
Competency tested for peer to peer review and assessment:
Please go through one student’s entire answer paper from this link, the one who is closest to your roll number:


And share your peer review of each answer with your qualitative insights into what was good or bad about the answer.

Answer:

My review of


My review of question 1:(review of the review)

1)PULMONOLOGY:

Review was done well with deep insights. Qualitative and Quantitative insights has also been noted well. A pie chart representing the review in terms of explanation, presentation and data gathering was also presented.

I completely agree with the review.

2) NEUROLOGY:

Review was well described. Etiology, medications and different reasons for patients symptoms has been well reviewed. Qualitative and Quantitative insights has also been noted well. A pie chart representing the review in terms of explanation, presentation and data gathering was also presented.

I completely agree with the review.

3) CARDIOLOGY:

Review was done well. Qualitative and Quantitative insights has also been noted well. A pie chart representing the review in terms of explanation, presentation and data gathering was also presented.

I completely agree with the review.

4) GASTROENTEROLOGY(&PULMONOLOGY):

Review was brief and well presented. Qualitative and Quantitative insights has also been noted well. A pie chart representing the review in terms of explanation, presentation and data gathering was also presented.

I completely agree with the review.

5) NEPHROLOGY:

Review has been done well. Cause for shortness of breath(SOB)in the patient (due to usage of diuretics) was noted. Qualitative and Quantitative insights has also been noted well. A pie chart representing the review in terms of explanation, presentation and data gathering was also presented.

I completely agree with the review.

6) INFECTIOUS DISEASE( HI VIRUS, MYCOBACTERIA, GASTROENTEROLOGY, PULMONOLOGY):

Review was brief and well presented. Qualitative and Quantitative insights has also been noted well. A pie chart representing the review in terms of explanation, presentation and data gathering was also presented.

I completely agree with the review.

7) INFECTIOUS DISEASE AND HEPATOLOGY:

Review was good. Qualitative and Quantitative insights has also been noted well. A pie chart representing the review in terms of explanation, presentation and data gathering was also presented.

I completely agree with the review.

8) INFECTIOUS DISEASE( MUCORMYCOSIS, OPHTHALMOLOGY, OTORHINOLARYNGOLOGY, NEUROLOGY):

Review was well illustrated. Qualitative and Quantitative insights has also been noted well. A pie chart representing the review in terms of explanation, presentation and data gathering was also presented.

I completely agree with the review. 

9) INFECTIOUS DISEASE( COVID-19):

Review was well presented. Reference link to different studies about effect of using steroids in COVID patients & Role of auto immune response in COVID patients has been provided. Qualitative and Quantitative insights has also been noted well. A pie chart representing the review in terms of explanation, presentation and data gathering was also presented.

I completely agree with the review.

10) MEDICAL EDUCATION: 

Review has been well presented on the current medical education during this pandemic.


My review of question 2:


This is a case of 55 year old male with anasarca secondary to right heart failure.

Chief complaints of the patient were well noted in chronological order. History of present illness was depicted well in a orderly manner. Past and personal history along with family history of the patient was taken. Appropriate pictures showing generalised anasarca were uploaded without revealing the identifiers. Local examination on CVS, RS, Abdomen and CNS is well reported. Clinically relevant  investigations has been done on the patient. Treatment plan of different medications along with their dosage and dose rate has been given.


My review of question 3&4: 

Overall presentation is great. Different reasons for performing relevant clinical interventions has been well explained. In the treatment plan, reasons for each medication has been addressed.


My review of question 5:

Couldn’t agree more. This tele-medical learning is really a wonderful and innovative way to learn in this lockdown.




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.





Question 3:
 (Testing peer review competency of the examinees):
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.


Answer:-

1.
Link:

AKI:

Chief complaints of the patient were well presented in chronological order. History of present illness and history of past illness of the patient were also presented in orderly manner. Treatment history, personal history and family history were also noted.
Physical and systemic examination were also presented well.
Relevant investigations were done. Treatment with dosage and dose rate was also given.
Overall presentation was fine. Besides all other aspects were well demonstrated.


2.
Link:

ACUTE ON CKD:

The case was well presented covering all clinically essential data.
Investigations done were in order.
Treatment plan was also noted well.


3.
Link:

CKD:

Data was excellently captured in an order wise manner.
Clinically relevant investigations were done.
Treatment data was also presented well.


4.
Link:

COMA AND RENAL FAILURE:

Brilliant presentation.
Clinically relevant investigations were done.
Day to day treatment plan was well noted.
At the end discharge summary was given which gives overall understanding of the case.


5.
Link:

COMA AND RENAL FAILURE:

Fabulous presentation. Data was captured systematically.
Useful lead investigations were done.
Day to day treatment plan was noted.
Discharge summary was also provided at the end.


6.
Link:

ACUTE ON CKD:

All the necessary clinical data was well noted. Crucial information of the case were separately highlighted. 
Clinically relevant investigations were done.
Necessary treatment plan was also given.


7.
Link:

ACUTE ON CKD:

Brilliant presentation.
Clinical data was well evaluated. Critical information were also separately highlighted.
Clinically relevant investigations were done and systematically arranged.
Treatment plan was also given.


8.
Link:

ACUTE ON CKD:

The case was well presented.
Necessary lead investigations were done. Treatment plan was also noted well.


9.
Link:

AKI:

Wonderful presentation. Clinical data was systematically provided.
Examination pictures were uploaded without revealing the identifiers.
Necessary investigations were done.
Day to day treatment plan was noted accordingly.


10.
Link:

AKI:

Clinical data was well captured in order.
Clinically relevant investigations were done.
Day to day treatment plan was done.


11.
Link:

AKI:

The case was overall well presented. 
Necessary clinical investigations were done.
Treatment plan was provided accordingly.



Question 4:
Testing scholarship competency of the examinees ( ability to read comprehend, analyse, reflect upon and discuss captured patient centered data as in their ‘original’ answers to the assignment for May 2021)

Please analyse the above linked patient data by first preparing a problem list for each patient and then discuss the diagnostic and therapeutic uncertainty around solving those problems. Also include the review of literature around sensitivity and specificity of the diagnostic interventions mentioned and same around efficacy of the  therapeutic interventions mentioned for the patient.


Answer:

1.
Link:

AKI:

Problem list:

  1. Lower abdominal pain ( sudden on onset ) from past 1 week
  2. Burning micturition from past 1 week
  3. Low back ache after lifting weights
  4. Dribbling/Decreased urine output from past 1 week
  5. SOB
  6. Loss of appetite from 1 week
  7. Irregular bowels
  8. IVP increased
  9. Tenderness present ( in supra public pain RIF )
  10. High TLC
  11. High blood urea
  12. High serum creatinine 
  13. Plenty of puss cells seen in urine ( >10/HPF )
  14. Low serum albumin
Provisional diagnosis:

AKI secondary to UTI, Associated with Denovo - DM 2
With ? Right heart failure
With K/C/O - HTN

Diagnostic interventions:

All the relevant investigations were done -
Hemogram, CUE, RFT, LFT, ECG, 2D Echo, Chest x ray, FBS, PLBS, HbA1c, bacterial culture and sensitivity report, ABG and SARS-COV-2 Qualitative PCR to rule out COVID

Therapeutic interventions:

Necessary therapeutic interventions were done -
  1. IVF : RL&NS @ UO+ 30ml/hr
  2. Salt restriction < 2.4 gm/day 
  3. INJ TAZAR 4.5 - 2.25gm IV/TID for Urinary tract infection
  4. INJ PANTOP 40mg IV/OD
  5. INJ THIAMINE 1 AMP in 100ml NS IV/TID
  6. INJ HAI S/C
  7. SYP LACTULOSE 15ml PO/TID as a laxative
  8. GRBS - 6th hourly
  9. BP/PR/TEMP - 4th hourly
  10. I/O - Charting 


2.
Link:

ACUTE ON CKD:

Problem list:

  1. Lower backache since 10 days
  2. Dribbling of urine since 10 days
  3. Pedal edema since 3 days
  4. SOB at rest since 3 days
  5. Increased involuntary movements of both upper limbs since 10 days
  6. Weakness tingling sensation and numbness of both upper and lower limbs since 3 days
  7. Bilateral pedal edema ( R>L )
  8. Left upper limb edema
  9. Dyspnoea grade 4
  10. Low serum albumin 
  11. High blood urea
  12. High serum creatinine 
  13. On CBP - Low Hb, slightly high TLC
  14. High Uric acid
  15. Few pus cells seen on bacterial culture and sensitivity report/urine culture
  16. High serum phosphorus 
  17. RFT - High levels of urea, creatinine, uric acid and phosphorus.

Provisional diagnosis:

Acute renal failure (intrinsic)
Grade 1 L4-L5 Spondylodiscitis, Multifocal infectious spondylodiscitis
Hyperuricemia secondary to renal failure
Uraemia induced tremors(resolved)
Delerium secondary to septic / uremic encephalopathy(resolving)


Diagnostic interventions:

All the relevant investigations were done -
ECG, RFT, CUE, Hemogram, ABG, Serum electrolytes, Blood urea, USG Abdomen, LFT


Therapeutic interventions:

Treatment was given on day to day basis for 10 days
All the necessary therapeutic interventions were given to the patient


3.
Link:

CKD:

Problem list:

  1. Generalised weakness from 20 days
  2. Vomiting from 3 days, non projectile, non bilious
  3. Pedal edema
  4. Facial fluffiness
  5. Yellowish discolouration of stools
  6. Lost appetite
  7. Restricted movement in the right wrist joint
  8. Pallor is present
  9. High blood urea
  10. High serum creatinine 

Diagnosis:

CKD? Chronic interstitial nephritis secondary to plasma cell dyscariasis, (multiple myeloma - 70% plasmacytosis)

Diagnostic interventions:

Hemogram, ABG, Serum electrolytes, CUE, LFT, ECG, Colour Doppler 2D echo, bone marrow aspiration, serum protein electrophoresis, USG Abdomen, Serum B12 and Iron profile

Therapeutic interventions:

Relevant treatment was given to the patient on daily basis -
Inj optineuron 1 amp in 500ml NS IV/OD
Ivf NS RL @ UO + 30 ml/hr
Inj erythropoietin 4000 IV S/C weekly twice
Tab pan-d PO/OD 
Tab orofer-xt PO/BD
Protein x powder 2 tsp in 1 glass of milk PO/TID
Tab softer 4mg PO/SOS 


4. 
Link:

COMA AND RENAL FAILURE:

Problem list:

  1. Fever and diarrhoea since 5 days
  2. Back pain with abdominal and chest pain
  3. Pallor is present
  4. Cns examination : Unconscious / altered 
  5. Low Hb 
  6. LFT: Elevated ALP, Increased AST, Decreased albumin levels
  7. RFT : High levels of urea, creatinine, uric acid
  8. Bed sores

Provisional diagnosis:

DKA with AKI(? Pre renal)

Diagnostic interventions:

ABG, CBP, LFT, RFT, Bacterial culture & sensitivity report, CXR, Hemogram, 2D echo, MRI, CUE

Therapeutic interventions:

All the necessary therapeutic interventions were given to the patient


5.
Link:

COMA AND RENAL FAILURE:

Problem list:

  1. Abdominal distension from past 7 days
  2. Constipation from the past 5 days
  3. Altered sleep patterns from the past 5 days
  4. Hiccups since morning
  5. Pedal edema grade 2 
  6. Elevated TLC
  7. RFT: Elevated levels of urea, creatinine, uric acid 
  8. LFT: Elevated AST and ALP
  9. Few pus cells seen on culture
  10. MRI: Multiple small acute infarcts noted involving bilateral cerebellar and cerebral hemispheres 
Final diagnosis:

Infective endocarditis with AV Vegetation with moderate AS severe AR 
With AKI
With ? Uremic encephalopathy ? Septic encephalopathy 
With ulcer over sole of right leg
With hypoalbuminemia ? Alcoholic liver disease 
With acute multiple infarcts in bilateral cerebral and cerebellar hemispheres

Diagnostic interventions:

CUE, Hemogram, RFT, LFT, ECG, 2D Echo, ABG, Bacterial culture and sensitivity report, CBP, MRI - Brain

Therapeutic interventions:

All the necessary therapeutic interventions were given to the patient


6.
Link:

ACUTE ON CKD:

Problem list:

  1. Decreased appetite and generalised weakness 
  2. SOB on exertion since 4 days
  3. High grade fever since 2 days associated with chills and rigor
  4. Burning micturition since 4 days
  5. Raised creatinine levels
  6. Fleshy mass like and foamy passage in his urine 6 days back
  7. Pus in urine
  8. Decreased appetite 
  9. Increased bladder frequency 
  10. On hemogram - low Hb, increased TLC, low RBC count

Diagnosis:

Renal AKI secondary to urosepsis with B/L hydroureteronephrosis with K/c/o DM-2 since 5 years with diabetic nephropathy with anemia secondary to CKD with grade 1 bed sore


Diagnostic interventions:

Hemogram, ECG, CXR, Bacterial culture and sensitivity report, CBP, CUE, Serological investigations, blood urea, serum creatinine, ABG, 2D Echo, NCCT KUB.


Therapeutic interventions:

All the necessary therapeutic interventions were given to the patient

Inj pantop 40mg iv/OD
Inj piptaz 4.5 stat and 2.25 gm iv/TID 
Injection LASIX 40mg iv/bd 
Inj optineuron 1 AMP in 100ml NS slow iv/OD 
Inj nedmol 100ml iv/sos
Tab PCM 650mg TID
Insulin human actrapid - 16 IU/ TID


7.
Link:

ACUTE ON CKD:

Problem list:

  1. Shortness of breath grade II from past 1 week which converted into grade III - IV from the past 4 days.
  2. Orthopnoea and bendopnoea
  3. Irregular bowel movements 
  4. Edema of feet present 
  5. Dyspnoea is present
  6. FBS, PLBS elevated 
  7. ESR elevated 
  8. Lower Hb
  9. Slightly increased ALP
  10. Slightly elevated triglycerides 
  11. RFT - High urea and creatinine 

Provisional diagnosis:

HFrEF secondary to CAD; CRF


Diagnostic interventions:

CBP, FBS, PLBS, HbA1c, ESR, ABG, LFT, Lipid profile, USG Report, 2D Echo, ECG, Bacterial culture and sensitivity report, Pulmonary function test.


Therapeutic interventions:

All the necessary therapeutic interventions were given to the patient 



8.
Link:

ACUTE ON CKD:

Problem list:

  1. Pedal edema since 3 days
  2. Decreased urine output since 3 days
  3. SOB
  4. Anasarca
  5. Vomitings
  6. Loose motions
  7. Very high levels of serum creatinine 
  8. Very high levels of blood urea
  9. Low SPO2
  10. Increased levels of C3 & C4 Serum complements 

Diagnostic interventions:

USG, 2D Echo, ECG, Hemogram, CUE, Serum electrolytes, serum creatinine, blood urea, CXR, HRTC, ABG, RFT, CBP, C3&C4 Complement panel serum

Therapeutic interventions:

All the necessary therapeutic interventions were given to the patient 

1. IV fluids
2. Tab. Pan 40 mg po OD 
3. Inj. Lasix 80 mg IV BD
4. Thiamin 200 mg in 100 ml NS IV BD
5.Tab. Levocet 5 mg Po BD
6.Liquid paraffin for LIA
7.Grbs 6 th hrly
8.I/o charting, temp. Charting 



9.
Link:

AKI:

Problem list:

  1. Loose stools watery in consistency since 20 days
  2. Bilateral Pedal edema up to knee since 20 days
  3. Abdominal distension since 20 days
  4. Pallor is present 
  5. Increased levels of serum creatinine 
  6. Low levels of albumin

Provisional diagnosis:

ALCOHOLIC HEPATITIS ,
AKI SECONDARY TO ACUTE GASTROENTERITIS  
HFrEF SECONDARY TO CAD 
ALCOHOLIC AND TOBACCO DEPENDENCE SYNDROME 


Diagnostic interventions:

Hemogram, CUE, CBP, RFT, LFT, ECG, CXR, USG, PT/ INR, APTT, BT/CT,.


Therapeutic interventions:

All the necessary therapeutic interventions were given to the patient 

INJ THIAMINE 100 mg in 100 ml NS slow IV / TID
INJ OPTINEURON 1AMP in 100 ml NS slow IV / OD
INJ LASIX 40 mg
TAB. ALDACTONE 50 mg PO / BD
INJ PANTOP 40 mg IV/ OD
ABDOMINAL GIRTH MEASUREMENT DAILY
BP /PR/TEMP/ RR -4 hourly 
I/O CHARTHING


10.
Link:

AKI:

Problem list:

  1. High grade fever since 10 days
  2. Bilateral pedal edema since 10 days
  3. Decreased urine output since 10 days
  4. Burning micturition 
  5. High BP
  6. High levels of serum creatinine 
  7. High levels of blood urea
  8. High TLC

Provisional diagnosis:

Acute kidney injury secondary to urosepsis

Diagnostic interventions:

CUE, ECG, USG, Serum creatinine, FBS, RBS, Blood urea, serum electrolytes, Hemogram, ABG, Bacterial culture and sensitivity report, CBP

Therapeutic interventions:

All the necessary therapeutic interventions were given to the patient



11.
Link:

AKI:

Problem list:

  1. Pain in abdomen since a week (epigastric region non radiating intermittent type)
  2. Vomiting since a week 
  3. SOB since a week
  4. Pedal edema is present 
  5. Low SPO2
  6. Raised SGOT
  7. High levels of serum creatinine 
  8. High levels of serum urea

Provisional diagnosis:

Acute pancreatitis with AKI 
With ? B/L Pleural effusion and moderate ascites

Diagnostic interventions:

LFT, Hemogram, ECG, CXR, USG, Bacterial culture and sensitivity report, ABG, Serum electrolytes, serum creatinine, blood urea, CBP

Therapeutic interventions:

All the necessary therapeutic interventions were given to the patient on day to day basis.




Question 5:
Testing scholarship competency in logging reflective observation on your concrete experience of this last month
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 at home.


Answer:

My tele-medical learning experience:

This month login experience was Wonderful. Most interesting part for me during this month was when I saw a patient with Diabetic chorea. In here I correlated to its physiology. I have also seen many patients with ranging from Cardiac to Renal problems, DKA, Liver & CNS issues and many more. Through this I somewhat got acquainted to hospital environment.

By going through many e blogs and also with this assessment I learned many clinical related aspects.

Only problem was some sort of audio and video connectivity. Besides these, everything else was fine. 

I really thank Dr Rakesh Biswas sir and all other PGs, interns and everyone for their efforts for letting us to learn from home during this pandemic.

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