General Medicine paper for Bi-monthly blended assessment - July 2021

I have been given the following cases to solve in an attempt to understand the topic of "Patient clinical data analysis" to develop my competency in reading and comprehending the clinical data including history, clinical findings, Investigations and diagnosis and come up with a treatment plan.

Link for the respective question paper : http://medicinedepartment.blogspot.com/2021/07/medicine-paper-for-july-2021-bimonthly.html?m=1

Written below are my answer to the given questions :

Main topic of the case data analysis: Renal Failure

Question 1 : Competency tested for Peer to Peer review and Assessment

Reviewed case link : https://mutyapuraghavendra.blogspot.com/

A)

Question 1 : Pulmonology

1) As the peer review states, well explained with relevant diagrams and the etiology, symptomatology, pharmacological and non-pharmacological treatments of this case of Acute Exacerbation (A.E) of C.O.P.D associated with right heart failure and bronchioectasis.

2) The reason for the bronchioectasis associated COPD can be also associated with Silicosis (common occupational disease caused by cement inhalation) as the patient in question is from a place where Cement factories are abundant, due to rich calcium deposits by the riverside. 

3) Under the Head end elevation or Head-of-bed elevation (HOBE) procedure, the relevant study was not mentioned. This also brings the topic that under every hypothetical statement there must be a relevant study to prove how much truth it holds so everyone can benefit from it properly. The reviewer should try to point this out.

Question 2 : Neurology

1) I agree with the review yet again, symptomatology well explained. Diagrams should've been included if possible.

2) Also, thiamine was highlighted as it controls and mostly reverses back the disorder and it's associated diseases such as optical neuropathy etc.

Question 3 : Cardiology 

1) The original answer was really well written with relevant representation as about biomarkers differences in both heart failure due to reduced vs preserved ejection fraction, as mentioned by the reviewer.

2) The statement about NSAID abuse deserves some recognition, as 

Question 4 : Gastroenterology and Pulmonology 

1) This case of pancreatic and lung inflammation is explained well, along with prophylactic treatments such as B1 supplementation, so that the long term TPN doesn't cause B1 deficiency and henceforth, Wernicke's encephalopathy as described in the earlier case. This is a good example of Pharmacovigilance.

2) Treatment with pharmacological and non pharmacological methods is also described well, former with drugs like Metrogyl, Amikacin, Ocreotide etc. I agree with the reviewer.

Question 5 : Gastrology 

1) As I would like to stress agin, when stating a new hypothesis, it's better to post the relevant study underneath it as a reference for the readers to avoid confusion.

2) Etiology, pathophysiology and pharmacological, non pharmacological effects were briefly explained, could've been explained a little more and as reviewer mentioned, no drug doses mentioned.

Question 6 : Nephrology 

1) As reviewer stated, etiology, pathophysiology and pharmacological aspects are well noted.

2) Could have included more pictoral representation 

Question 7 : Infectious diseases (HIV, Mycobacteria, Gastroenterology, Pulmonology)

1) Everything from the history of the patient to the treatment given is explained well here, along with pictures.

2) Also, the reason for increased biomarkers such as LFTs also explained well. 

Question 8 : Infectious diseases and Hepatology 

1) I agree withthe reviewer.  

2)Etiopathogenesis, line of treatment are well explained with pictures.

Question 9 : Infectious diseases (Mucorrhmycosis)

1) This newly widespread complication due to excessive steroidal usage in the treatment of COVID-19 pandemic must be given prime importance for further studies.

2) The relevant studies with links were posted here, along with pictorial representation which is highly commendable.

3) This case proves that not only the SARS-CoV2 infection, but also Diabetic ketoacidosis and HTN can also cause this disease and it's not a new, but simply a newly widespread occurrence 

Question 10 : Infectious diseases (COVID-19)

1) Etiopathogenesis can be described even better with relevant pictures, but good explanation for everything, including the line of treatment, relevant diagnostic procedures done etc.

2) Relevant studies along with links are provided, which is very commendable. I agree with the reviewer.

B)  

C)  QUADRIPARESIS ASSOCIATED WITH INF. SPONDYLITIS & EPIDURAL ABSCESS

1) Reviewer has covered everything satisfactorily, for this case of Quadriparesis (weakness of all 4 limbs) associated with Infectious Spondylitis and epidural abscess.

2) These include the History, general and systemic examinations along with the relevant biochemical, pathological and other diagnostic tests done

3) Etiopathogenesis should also have been explained a little beforehand. Pharmacological and non pharmacological line of treatment also explained well.

D)  HEART FAILURE W/ REDUCED EJECTION FRACTION (HFrEF) W/ ATRIAL FIBRILLATION

1) Overall review of the case is good. Reviewer has observed the line of treatment, relevant diagnostic procedures performed and the history of the patient

2) Also, the reviewer seems to have followed up the prognosis until the patient's death, instead of leaving it at the line of treatment which is seen in the review.

E) TELEMEDICINE EXPERIENCE REVIEW

• I do agree with the reviewer, as these online classes are very different from what most of us have experienced through out our lives, sitting at the comfort of our homes and listening to classes still feels anew to us.
• But since this would probably become a new normal for all of us, teacher or student or non teaching staff, we must adapt to this situation as fast and better as possible just like a bacterium or a virus becomes resistant to a new antibiotic or a new vaccine (considering the rapid growth of technology this century is seeing)
• But this whole process was made much more easier and efficient thanks to our wonderful, hardworking HOD sir, the PGs, interns and all other medical and non medical staff, IT personnel and respected principal ma'am for making this long distance education possible for all of us. They are making this possible even in such harsh times where they're risking their own lives for the sake of education which is highly respectable. My heartfelt gratitude lies with all of you.

Question 2: 

Question 3 : 

CASE 1 : 

Provisional Diagnosis : 

1) Acute Kidney Injury (AKI) secondary (2°) to denovo DM-II

2) With (?) Right Heart Failure 

3) With K/C/O HTN with no Rx 

• Well noted and explained diagnosis, could explain a bit more
• Well captured history, physical and systemic examinations of the patient along with properly dated serological investigations and other diagnostic procedures.
• Relevant pictures have also been posted without identifications, which is recommended. 
• A discussion section could've been provided under the blog so they can post their own thought process with both their queries and the answers for them.

CASE 2 : 

Provisional diagnosis :  Acute renal failure and few associated diseases 

• Good presentation 
• Well noted, with all related pictures of the reports and line of treatment
• Couldve briefly explained underneath as to why the relevant drugs are used in what condition 

CASE 3 :

Provisional Diagnosis: CKD? Chronic interstitial nephritis 2° to plasma cell dyscariasis 

• Nice presentation 
• Along withthe usual details, a follow up of the patient has also been posted which should be done if possible.

CASE 4 : DKA with AKI ? prerenal 

• Good presentation 
• Again, a discussion section can be opened and description of drug usage in this case can be given 

CASE 5 : HFrEF 2° to CAD, CKF

• Really appreciable presentation.
• All related pharmacological and non pharmacological line of treatments also mentioned well along with history, general and systemic examination, and the diagnostics with reports 
• What's commendable is adding the related links and presenting them in a proper format to clarify the readers on this topic.

CASE 6 : Alcoholic hepatitis and AKI 2° to gastroenteritis

• Good presentation 
• Can post some discussion for the line of treatment and diagnosis, but well explained and represented case

Question 4 : 

CASE 1 : 

Problem list : 

1) Lower abdominal pain

2) Burning micturition

3) Lower back ache after lifting weights

4) Dribbling/decreased Urine output

5) SOB (grade 4), fever

6) Blurring vision and blackouts

7) Abnormal bowels, tenderness in supra pubic area RIF

Diagnostic Uncertainties

1) Mild Hepatomegaly with Grade 1 Fatty Liver - Due to Obesity

2) HbA1C levels are slightly low.

3) Urine analysis shows high levels of serum creatinine, blood urea and reduced sodium and chloride levels and polymicrobial flora infection is seen (pus cells in urine) - INDICATING UTI. 

4) All these elevated waste levels in the urine analysis and the ABG report cause AKI.

5) • As stated in this particular case study, it's been observed that in UTIs, there's increased vascular permeability causing interstitial leaking of neutrophils and macrophage causing increased inflammation and hence causing AKI. This is the relevant link : https://www.google.com/url?sa=t&source=web&rct=j&url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4516244/%23:~:text%3DInterstitial%2520infiltration%2520of%2520neutrophils%2520and,kidney%2520and%2520resulted%2520in%2520AKI.&ved=2ahUKEwiqjJPsof3xAhWbbysKHaYGBhoQFjABegQIDRAF&usg=AOvVaw3oajXc3O0Z3TNYWWD2-j-T&cshid=1627183451637

• As described in this link : https://www.google.com/url?sa=t&source=web&rct=j&url=https://oxfordmedicine.com/view/10.1093/med/9780199592548.001.0001/med-9780199592548-chapter-248&ved=2ahUKEwjvzumppP3xAhWUqksFHWKKAPI4ChAWMAR6BAgHEAI&usg=AOvVaw0rYlU8Sc8nJCl7GR-Q55IQ

It's proven that Acute Heart Failure (AHF) causing AKI is classified as Cardiorenal Syndrome (CRS) Type I. It can be caused by factors like Venous congestion and inflammation mainly in this case by Obesity, but can also be caused by certain drugs like ACE inhibitors, which act on RAAS mechanism.

• This is obviously observed in the ABG report of the individual, with the abnormal values.

Therapeutic Uncertainties

1) Thiamine supplementation given to avoid Beri Beri, Wernicke's encephalopathy as the patient is a regular consumer of alcohol.

2) Tazar (tazobactam) is a beta lactamase inhibitor antibiotic, to act againsg the UTI in this case and also other infections such as nosocomial pneumonia, uterine infections etc

3) Salt restriction done to reduce the burning micturition and the excess urine output and incontinence.

4) To control the dehydration as a result, Ringer lactate is given IV continuously, other cases where it's commonly given is burns.

5) PCM to control any fever signs and Ultracet as a painkiller is given. HAI (Human Insulin Injection) is given to control the blood sugar.

All these issues were well addressed.

CASE 2 :

Problem list 

1) Lower backache after lifting weights, SOB

2) Dribbling urine

3) Pedal edema - pitting type

4) Increased involuntary movements of all 4 limbs 

Diagnostic uncertainties

1) Dyspnoea Grade 4 

2) Slurred speech

3) Bacterial culture report positive with Staphylococcus aureus infection, explaining the increased WBCs seen in the CBP (Neutrophilic leukocytosis)

4) MRI Spine also reveals infectious Spondylodiscitis (lumbar, dorsal and cervical) seen by disc degeneration, displacement of spinal cord seen at these levels. This explains the poor reflexes such as the bad ankle jerk reflex

5) Raised Blood urea and creatinine levels and pus cells also indicate septic uremia

Therapeutic Uncertainties

1) Tazar (tazobactam) antibiotic used for septic infections. It also facilitates Piperacillin's action further.

2) Lasik is used for blocking Na,Cl and water reabsorption, increasing their excretory output.

3) Salbutamol - bronchodilator helps for dyspnoea

4) Piptaz - a combo of Piperacillin and Tazobactam, it's used to treat infections such as UTIs, bone infections, tonsillitis, sinusitis.

5) Optineuron given as vitamin supplement and Febuxostat for reducing hyperuricemia and thereby preventing gout.

CASE 3 :

Problem list

1) History of backaches, followed by NSAIDs usage

2) Non bilious, non projectile vomitings, increased per anal bleeding

3) Pallor present

Diagnostic uncertainties

1) Abnormal ABG report - shows some renal dysfunction.

2) Also, increased blood urea and creatinine seen , Dimorphic anemia, pus in the urine is observed as Chronic interstitial nephritis. It's confirmed by USG Abdomen  - bilateral grade 2 RPD (Renal Parenchymal Disease).

3) Plasma cell dyscrasias such as Multiple myeloma is confirmed by the pain in the right wrist joint and in the blood tests like Bone marrow aspiration and Serum electrophoresis presence of M protein.

Therapeutic uncertainties

1) Protein X is given to boost immunity and also help replacing the cancerous plasma cells in the bone marrow of affected bones with healthy blood cells.

2) Zofer given as treatment for nausea and vomiting

3) Nodosis reduces gastric acidity, metabolic acidosis such as in urine and blood

4) Supplements like Orofer, Erythropoetin, Optineuron are given for the patient's anemia

CASE 4 : 

Problem list

1) Fever and diarrhea with bloody discharge, back pain 

2) Type 2 DM on some oral hypoglycemic drugs 

3) High GRBS

4) Infection on little finger

5) Back pain on using antibiotics

6) Altered sensorium

7) Vomitings, diarrhoea

Diagnostic uncertainties

1) Severe metabolic acidosis seen in ABG, so put on ventilator

2) Soft and tender abdomen on per abdomen

3) DKA with AKI ? (prerenal)

4) Unconscious, no speech response

5) Acute pyelonephritis, severe bed sores seen as pt. In prolonged vegetative state, cutting off blood supply to the area.

6) Hyperintensity of bilateral temporal lobes

Therapeutic uncertainties

1) Complete debridement of bed sores done until muscle and supplied with antibiotics, facilitating proper healing.

2) NORAD and DOPAMINE also given, former for raising BP, to treat the sepsis of the bed sores and latter for the same and also to jncreae cardiac output and blood flow to kidneys.

3) Antibiotics like Levofloxacin and Vancomycin are used

Question  5 :

• My experience with telemedicine and these online classes has been mostly good, the only problem was the connectivity issues with audio and video
• Other than this, I really want to thank Dr.Rakesh Biswas sir, the PGs and interns and all the related medical and non medical staff taking care of the patients in the wards and making these classes possible for us. 
• This new type of education has to be adapted as soon as possible by us to keep up with the rest of the world and be good medical professionals even considering the current situation of the world.