GENERAL MEDICINE ASSIGNMENT, JUNE 2021
Thota Vaishnavi, roll no 133.
We have been giving 5 questions to assess the ability to connect with and capture patient centered data and ability to connect with and engage in shared learning with their peers through peer review feedback.
Answer 1:
Review: A 55 year old female patient, a resident of Miryalaguda and farmer by occupation came to the hospital on 17/5/21 with the chief complaints of shortness of breath, pedal edema and facial puffiness.
Past history with episodes of SOB were mentioned clearly. The whole treatment was listed. All the reports and images are clear.
Review: Patient was examined carefully and referred to all the departments required. All the pictures of him are deidentified.
Review: All the investigations were listed clearly. CT scan images are clear.
Patients details are not shown in any reports, x rays. Reports are not clear.
Vitals are noted properly. Reports are not soo clear but, conclusion was given. Treatment line was good.
History taking was good. But explanation of the case was vague. Treatment line was good.
As a whole elog was good, understandable. Treatment line was good.
The reason for elevation of values was not mentioned. Diagnosis and treatment line was good.
The reason for elevation of biomarkers is not mentioned. Patients details are deidentified in the reports. Treatment line was good.
Case presentation was a little clumsy. Images were clear and explanation was good.
Question 2. Make an elog.
I didn't get any case to make an elog till now. As soon as I complete doing it, I'll upload here.
Question 3 and 4.
A CASE OF A 45 YEAR OLD MALE WITH ACUTE KIDNEY INJURY ON CHRONIC KIDNEY DISEASE (HYPERTENSIVE NEPHROPATHY) WITH URAEMIC ENCEPHALOPATHY.
A 45 year old came to the hospital on 21/06/2021, with complaints of altered sensorium and fever 10 days back. Followed by Pedal edema with Anasarca with Shortness of breath present even at rest .
Patient was apparently asymtomatic 5 Years back,then he Complained of lower back pain and neck pain in 2014 and was found to have creatinine of 3.0 mg/dl for which he was managed symptomatically for 1Year.
Patient didn't come for further follow up after 2015 and attenders said that he was noncompliant in taking medications untill last week when he Came with the complaint of Shortness of breath even at rest(grade 4) and loss of appetite .
PROVISIONAL DIAGNOSIS:
AKI ON CKD(HYPERTENSIVE NEPHROPATHY) WITH URAEMIC ENCEPHALOPATHY.
PLANNING FOR HEMODIALYSIS.
Treatment:
IVF-NS(0.0+30ml/hr)
INJ.LASIX(40mg/IV/TID)
INJ.NaHCO3(100meq in 100ml NS/IV/Stat)
T.NODOSIS 550mg/P.O/TID
BP/PR/Strict I/O Charting.
Question 5.Testing scholarship competency in
logging reflective observations on your concrete experiences of this last month
write an essay for 10 marks on the above topic.
Answer:
From past 1 month, we have exposure to various case studies, interaction with few patients online. During this pandemic online classes are very effective. But, without direct interaction with the patient it was difficult to understand the case.
Our PG's, interns, and Dr. Rakesh Biswas sir have been helping us through everything, making us understand about patients case. We have been learning case taking, history taking through online.
The elogs were of great help to learn many new things. This has paved a new way for learning things being at home. Gaining knowledge about this was only possible because of general medicine department. Hoping to learn more after going back to college.
