Hello everyone, I’m Thota Vaishnavi from 3rd semester, roll no 133.
We have been given the following cases to solve in attempt to understand the topic of ‘ Patient clinical data analysis’ to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and diagnosis.
This is the link of the questions asked regarding the case:
Click here
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 own roll number :
and share your peer review of each answer with your qualitative insights into what was good or bad about the answer.
Answer:
I have selected the following elog for reviewing :
Click here
Review for 1st Answer: All the cases and answers are studied well and reviewed. Score was given to each elog. Presentation is well and organised.
Review for 2nd Answer:
Briefing of the case: Patient was apparently asymptomatic 20 months ago, when he was admitted after he suffered a ?Transient ischaemic attack (TIA). Patient's family describe the symptoms as weakness of limbs and deviation of mouth (they were not sure which side).
He was admitted in a hospital in Hyderabad for 1 week. Medical records regarding reason for admission are not available. During this week, he was diagnosed to be an active case of Pulmonary koch's, for which he was on ATT for 6 months.
4 days back, patient developed weakness of limbs and slurred speech. He has been unable to walk and was also unable to swallow (solids and liquids) during these 4 days. He also has deviation of tongue to the right side.
Patient is a known case of TB since 18 months (1 and a half year) and was on ATT for 6 months.
Patient is a regular tobacco and alcohol consumer.
Impression from MRI scan:
1. Acute infarct involving right temporal and parietal lobes - MCA territory.
2. Old infarct involving inferior aspect of left cerebellar hemisphere.
3. Old lacunar infarct in left thalamus.
Final diagnosis:
CVA with acute infarct involving MCA territory involving right temporal and parietal lobes.
Review: All the details of the patient are deidentified. History of present illness and past and present illness is mentioned clearly. MRI scans images are a bit blurred. Treatment line is good. Every day’s treatment was mentioned. Vedios presented are clear and helpful for the diagnosis. General examination is detailed in an organised way.
Review for 3nd and 4th answers: A CNS case is taken from an e-log and summary, critical appraisal of the case is presented.
Positives and negatives of the case are mentioned well.
Review for 5th answer: Experience of online clinicals was shared based on own observations. Though there are some problems with online learning, we are thankful for our professors, PG’s and interns for guiding us through these tough times.
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.
Answer: A group of 5 to 6 students each was assigned an intern for guiding us to do e-log cases. Our ma’am was affected with COVID and is home quarantined right now. We will be able to do e-log once she gets back to hospital. I’m waiting eagerly for that opportunity.
Question 3: Testing peer review competency of the examines :
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) Patients with low back ache and renal failure :
AKI :
Review: A 58 year old patient came to the casualty with chief complaints of :
- Lower abdominal pain and burning micturation since 1 week,
- lower back ache after lifting weights,
- dribbling/ decrease of urine output since 1 week,
- fever and SOB, rest since 1 week.
Investigations ordered are Hemogram , CUE , RFT , LFT , ECG , 2D Echo , Chest X-ray , FBS , PLBS ,HbA1C.
★ PROVISIONAL DIAGNOSIS :
-Acute kidney injury( AKI) 2° to UTI, associated with Denovo - DM -2
-With ? Right HEART FAILURE,
-With K/C/O - HTN ( Not on Rx)
AKI causes a build up of waste products in your blood and makes it hard for your kidneys to keep right balance of fluid in your body.
2D echo and chest x-ray shows Acute kidney injury and right heart failure. HbA1C, FBS, PBLS shows he is associated with Denovo - DM -2. Bacterial culture and sensitivity report shows Urinary tract infection.
2) Acute on CKD :
Review : A 75 year old male patient, labourer by occupation, came to the casualty.
- Patient was apparently asymptotic 10 days back. Later developed lower backache after lifting of heavy weights 10 days ago, which is insidious in onset and gradually progressive with dull aching type of pain radiating to -right lower limb.
- Dribbling of urine.
- Pedal edema which is insidious in onset and gradually progressive, pitting type extending up to the knee.
- involuntary movements of both upper limbs since 3 days.
Investigations ordered- ECG, RFT, CUE, Hemogram, ABG , Serum electrolytes, Blood urea ,USG Abdomen ,LFT
USG ABDOMEN AND PELVIS showed Raised Echogenicity of B/L kidneys.
Other investigations led to the conclusion of probable diagnosis of :
Acute renal failure (intrinsic)
Grade 1 L4-L5 Spondylodiscitis ,Multifocal infectious Spondylodiscitis
Hyperuricemia 2° to Renal failure
Uraemia induced tremors( resolved)
Delerium 2° to septic /Uremic encephalopathy (resolving)
3) Patient with coma and renal failure :
Review : This is a case if renal failure. The patient is unconscious. Chief complaints of fever and diarrhoea, back pain with abdominal pain and chest pain.
Intubation and CPR was done.
Investigations ordered: ABG ANALYSIS, CBP, 2D ECHO, LFT, KFT, hemogram.
4) Patients with acute on CKD :
Review : A 52 year old male patient who is a farmer by occupation presented to hospital with chief complaints of fever since 4 days, pus in the urine.
Investigations ordered:
- CBP
- Chest X-ray
- ECG
- ABG Analysis
- NCCT KUB
Based on the investigations the patient was diagnosed with
Renal AKI secondary to urosepsis with b/l hydroureteronephrosis with K/c/of DM -2 since 5 hrs with diabetic nephropathy with Anemia secondary to CKD with grade 1 bed score.
5) Patients with AKI :
Review :
A 43 year old male, resident of Nalgonda came to casuality with chief complaints of - loose stools since 20 days.
- pedal edema since 20 days
- abdominal distension since 20 days.
INVESTIGATIONS:
Hemogram
CUE
CBP
RFT
LFT
ECG
CXR PA VIEW
USG ABDOMEN
PT/ INR
APTT
BT/CT
Based on these investigations patient was diagnosed with
ALCOHOLIC HEPATITIS ,
AKI SECONDARY TO ACUTE GASTROENTERITIS
HFrEF SECONDARY TO CAD
ALCOHOLIC AND TOBACCO DEPENDENCE SYNDROME
Question 4: Q4: Testing scholarship competency of the examinees ( ability to read comprehend, analyze, reflect upon and discuss captured patient centered data as in their 'original' answers to the assignment for May 2021):
Please analyze the above linked patient data by first preparing a problem list for each patient (based on the shared data) 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 each patient.
Answer :
1) AKI :
Review : Overall presentation is clumsy. Images are not clear. Treatment line is good. Presentation of history is not clear. Treatment line is good.
★ PROVISIONAL DIAGNOSIS :
-Acute kidney injury( AKI) 2° to UTI, associated with Denovo - DM -2
-With ? Right HEART FAILURE,
-With K/C/O - HTN ( Not on Rx)
- AKI causes a build-up of waste products in your blood and makes it hard for your kidneys to keep the right balance of fluid in your body.
TREATMENT:
1)IVF : -RL @ UO+ 30ml/hr
-NS
2)SALT RESTRICTION < 2.4gm/day
3)INJ TAZAR 4.5gm IV/TID
|
2.25gm IV/ TID
For urinary tract infection.
4)INJ PANTOP 40mg IV/OD
5)INJ THIAMINE 1AMP IN 100ml NS IV/TID
It is a supplement of vitamin B1. Vitamin B1 is essential for breaking down the glucose in the body and plays a key role in nerve muscle and heart function.
6)INJ HAI S/C ACC TO SLIDING SCALE
8AM - 2PM - 8PM
For diabetes mellitus - 2.
7)SYP LACTULOSE 15ml PO/TID [ To maintain stools less than or equal to 2]
8) T. ULTRACET PO 1/2 TAB QID
It is a narcotic pain reliever. It’s used to treat aches. As the patient has complaints of back ache.
2) Acute on CKD :
Review : Presentation is good. Images are clear. History taking is done well. Treatment line is good.
PROBABLE DIAGNOSIS
Acute renal failure (intrinsic)
Grade 1 L4-L5 Spondylodiscitis ,Multifocal infectious Spondylodiscitis
Hyperuricemia 2° to Renal failure
Uraemia induced tremors( resolved)
Delerium 2° to septic /Uremic encephalopathy (resolving)
TREATMENT
• Inj. Tazar 2.25gm I.V -TID
Used for urinary tract infection
• Inj. Lasix 40mg I.V -BD
Used for edema
•Nebulization Salbutamol -4th hourly
• Inj. Pantop 40mg I.V -OD
• Tab. PCM 650mg -TID
• Foleys catheterization
Used to pass urine from bladder.
• INJ. Neomol 1mg -I.V -SOS
Painkiller used to treat pains and aches
Inj. PIPTAZ 2.25gm -I.V -TID
An Antibiotic used for urinary tract infection.
3) Patient with coma and renal failure :
Review : Presentation is good. Investigations and reports are arranged well and impression in given.
Provisional diagnosis: DKA with AKI ( ? Pre renal)
Treatment :
Inj. NORAD 2amp in 50ml NS
Inj. PIPTAZ 2.25gm.
Inj. DOPAMINE 2amp in 50ml
Inj. HAI 1ml in 39ml NS
Day 2
Inj.HAI 1ml in 39mlNS
Inj. PIPTAZ 2.25gm.
Inj. CLEXANE 40gm.
Iv infusion NS RL @100ml/hr.
Day 3
Inj.HAI 1ml + 34ml NS
Inj. PIPTAZ 2.25gm
Iv infusion NS (urine output + 40ml/hr)
Inj. NORADRENALINE(2 amp+46ml NS)
Day 4,5 same as day 3
Day 6
Inj. PIPTAZ
Inj. LEVOFLOX
Inj. VANCOMYCIN
Day 7 and 8 same as day 6.
Day 9
Inj. MEROPENEM
Inj. LEVOFLOX
Inj.VANCOMYCIN
Day 10 and 11 same as day 9
Day 12
Inj. MEROPENEM
Inj. FOSFOMYCIN
Inj. CLEXANE
Day 13 and day 14 same treatment as of day 12 additionally Inj. LASIX was given.
4)
Patients with acute on CKD :
Review : Presentation is good. Patients details are deidentified. Images are clear. Treatment line is good.
Probable diagnosis: Renal AKI secondary to urosepsis with b/l hydroureteronephrosis with K/c/of DM -2 since 5 hrs with diabetic nephropathy with Anemia secondary to CKD with grade 1 bed score.
Treatment:
Injection PANTOP 40mg IV/OD
Injection PIPTAZ 4.5 stat and 2.25 gm IV/ TID
Injection LASIX 40mg IV/BD
Injection optineuron 1AMP in 100ml NS slow IV/OD
Injection NEDMOL 100ml IV/SOS
Tab PCM 650mg TID
Insulin Human actrapid - 16 IU/TID
5) Patients with AKI :
Review : Patients information is deidentified and presented in the log. This is a case of AKI. Patients history, reports are presented well.
PROVISIONAL DIAGNOSIS: ALCOHOLIC HEPATITIS ,
AKI SECONDARY TO ACUTE GASTROENTERITIS
HFrEF SECONDARY TO CAD
ALCOHOLIC AND TOBACCO DEPENDENCE SYNDROME
TREATMENT
- 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
Question 5 : Testing scholarship competency in logging reflective observations on your concrete experiences of this last month :
Answer : This platform of doing e-logs and reviewing assignments has been very useful in learning and knowing many case studies. It helped to understand patients pain and need. Solving each case was very interesting this way. Hoping to learn much more in coming days. I thank everyone who is guiding us through this difficult process of learning.
THANK YOU FOR GOING THROUGH THIS ASSIGNMENT
