General medicine Summative assessment - July 2021

Name -Prasannakalyan
Roll no - 52



Question-l 
Peer review 

Himaratsa-50

Case reviews-He has analysed all the cases after reading both the case report and the assessment and has come to varied conclusions on the cases, their prognosis, their treatments and the post discharge care received by the patient. He has gone into great detail about the causes and the solutions for the majority of the cases but has fallen short of criticism and has not provided valuable input and feed back that will help the doctors writing these cases improve their methodology. He has gone into detail of the cases after they have come to the op but has missed the root causes like alcoholism which could have caused the cases in the First place. Overall himaratsa has done very well and I have leant a lot from his assessment.

Case presentation E-Log  - no case log given

Case analysis - He has analysed a case of aki- acute kidney injury a 45 year old man.
Link - https://61tejarshini.blogspot.com/2021/06/general-medicine-case-discussion.html?m=1

He initially goes into a review of the case presentation. He then analyses the diagnosis of AKI and goes into the rational as to why it is aki. He comes to the conclusion that the AKI is because of CKD caused by hypertension and the patient has uremic encephalopathy. He then goes into the treatment given. He has gone through great effort to understand the complicated case given as many contributing factors are seen in the provisional diagnosis given. The author of the cases has not gone into detail about future management therefore that has also been missed in the case analysis. Overall an excellent effort has been made by both the case author and himavatsa to summerise the case given.

Overall my fellow peer has done a very good job doing the assessment considering that we had no prior experience and I am confident that both him and I can do a lot better over the course of our medical education.




Question-2

E log - https://prasannakalyan52.blogspot.com/2021/07/patient-history-2.html




Questions -3&4


A) AKI :

1.https://laharikantoju.blogspot.com/2021/07/58-year-old-male-patient-elog-lahari.html?m=1

The given case is of a 58 year old male with chief complaints of lower abdomen pain since 1 week with burning maturation & oliguria. Fever& sob (grade 4) is also seen. Patient has use of NSAIDs for back pain & headache and has common bouts of blurred vision & blackouts. 13 years ago trauma to head and is known case of hon but not under medical management. Regular alcohol intake is seen unto 3 times a week. During physical examination high bp seen (140/90 mm Hg ) and GRBS of 113mg% was seen, tenderness around suprapelvic with pain on right flank seen. Pus in urine with negligence albumin but elevated levels of serum creatinine [5.9] & blood urea (129) are seen.

Provisional diagnosis given - AKI due to idiopathic causes. Causes suspected include DM2 but no history seen, right ventricular heart failure but physical exam normal. Therefore HTN suspected but ultimate cause not determined.


Complaints & problems

Oligurea, burning mituration

Sob grade 4

Hypertension - 140/90 mm Hg

Elevated serum creatinine & blood urea


Solutions

IVF given - to induce mituration

Salt restricted

Bp regularly monitored

Diuretics given

Foleys catheter

Load on kidney reduced & patient is released on diuretics. Kidney will heal over time




B) AKI & CKD :

1.http://srinaini25.blogspot.com/2021/07/srinaini-roll-no-33-3rd-semester-this.html

The given case is of a 75 year old man with chief complaints of lower back pain since 10 days along with oliguria, pedal edema, sob& involuntary movements of limbs since 10 days. Patient has history of jaundice 3 years ago treated by plant based treatment. No known case of HTN, TB & DM. On general examination of CNS , slurred speech was seen with slightly reduced left upper and lower limb power with increased tone on lower leg. All reflexes were elicited. Severe anaemia is seen with increased blood urea and creatinine. 

Provisional diagnosis given -  Acute kidney injury with chronic renal failure. Uremic encephalopathy  and uremia induced tremors


Complains & problems  

Oligurea, burning mituration

Sob grade 4

Elevated serum creatinine & blood urea

Encephalopathy and tremors 


Solutions

IVF given - to induce mituration

Salt restricted

Bp regularly monitored

Diuretics given

Foleys catheter

Load on kidney reduced & patient is released on diuretics. Kidney will heal over time




C) CKD :

1.https://krupalatha54.blogspot.com/2021/07/a-49-yr-old-female-with-generalized.html?m=1

This is a case of a 49 year old female who had a mass 13 years ago with bleeding and was operated for hemoroids. Has been on NSAIDs for past 3 years for muscle aches. Has had 20 days of fever and general weakness. Has been vomiting for 3 days. No SOB seen and urine output is normal. No significance seen in personal history. Physical examination shows  restricted right and left knee joint movement and very deep palor. Complete blood profile shows Dimorphic anaemia is seen along with very low RBC count. Bilirubin elevated but conjugated bilirubin normal therefore excess breakdown of RBC is seen. LFTs normal. Hence RBC formation is suspected and Bone Marrow biopsy is aspirated

Provisional diagnosis - Multiple myeloma (plasmocytosis 70%)


Complaints and Problems 

Fever and General weakness

Severe and dimorphic Anaemia

Jaundice 


Solutions 

Erythropoietin injections are prescribed twice a week for the anaemia.   

Referred to higher centre


Case similar to the above given case 

This is an interesting case because the symptoms do not coincide with the classical presentations of Multiple myeloma. This is also seen in the other case seen by Dr Rakesh Biswas in 2009 where a 47 year old with lower back pain presented to the OP. Even after multiple ways to find the source of acute renal failure the cause could not be found. Finally after a month a CT and a bone biopsy showed the presence of multiple myeloma. This case helps us learn about multiple methods of presentation of the same disease.





D) Patient with coma and renal failure  :

1)https://ananyapulikandala106.blogspot.com/2021/06/a-35yr-old-female-elog.html

This is a case of a 35 year old female with diabetes melitus type 2 and SOB. Lower back pain since 5 days with abdominal and cheat pain. At time of admission GRBS was 580mg/dl, back pain since one year and worsened upon administering of non prescription antibiotics. Patient was immediately intubated as they were gasping for air. SpO2 60% was recorded. Severe Metabolic acidosis seen. Patient was stabilised but still remains in a comatose state. gangrene Formed on thigh removed surgically.

Provisional diagnosis -  DKA coma and AKI due to diabetic nephropathy


Complaints and problems 

Fever and SOB

High blood sugar levels

Low blood pH

Patient is comatose 

Gangrene 


Solutions 

Regular ABG done and pH maintained 

SOB stabilised by intubation 

High Sugar levels maintained by 10 units of insulin

Gangrene treated by cutting off flesh and underlying muscle 



2)https://pallavi191.blogspot.com/2021/06/gm-cases_30.html?m=1

This is a case of a 52 year old with chief complaints of abdominal distension since 7 days. Patient asymptomatic till 2 years ago then non healing injury to foot. Diagnosed with DM type II and was started on GIMI M2. Patient was admitted 7 days ago and 5 days ago they experienced constipation and altered sleeping patterns. 

Diagnosis - INFECTIVE ENDOCARDITIS
WITH AV VEGETATIONS 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


 

E)Patients with acute on CKD :

1)https://kavyasamudrala.blogspot.com/2021/05/medicine-case-discussion-this-is-online.html?m=1

This is a case of 52 year old man with diabetes mellitus type 2, since 3 months burning mituration with no association of fever, He was diagnosed with Prostomegaly (60gm) and advised TURP. Underwent TURP. Returned to hospital with complaints of excessive drowsiness and excess sleep. On third admission  there was high grade fever and burning micturation since 4 days. Creatinine levels 10mg/dl. Normalised and discharged. Finally admitted again with High grade fever and pus in urine. General examination revealed very low haemoglobin with anaemia and elevated serum creatinine. Blood urea was also slightly elevated with drop in levels of sodium. 

Probable diagnosis - Renal AKI with urosepsis and DM since 5 years and Diabetic nephropathy with anaemia due to CKD


Complaints and problems 

Fever and Burning urine 

Pus in urine 

Prostomegaly 

Elevated blood sugars 


Solutions 

Antibiotics for Prostomegaly and pus in urine 

TURP procedure for Prostomegaly 

Diuretics foroligurea and burning urine 

Huminsulin for elevated blood sugars 



2)https://rishikakolotimedlog.blogspot.com/2021/07/45-year-old-male-with-chief-complains.html?m=1

This is a case if a 48 year old man with acute shortness of breath worsening from Grade 2 to 3 to 4 from past 4 days. 2 years back he was diagnosed with Chronic renal failure and was given symptomatic treatment for the same. 7 months ago the patient had cheat pain with heart failure and after an angiogram he felt wrong. SOB over the course of 2 months increasing in grade over the course of last week. On general examination pedal oedema, dyspnoea present but wheezing absent. No abnormalities seen in CNS examination with 15/15 on the Glasgow scale. FBS and PLBS elevated, Complete blood picture showed low HB. 

Provisional diagnosis - HFrEF reduced ejection fraction secondary to CAD and CRF


Complaints and problems 

Shortness if breath


Solution

Beta blockers given to help with the congestive heart failure and elevates the Shortness of breath



3)https://krupalatha54.blogspot.com/2021/06/this-is-online-e-log-book-to-discuss.html?m=1

This is a case of 60 year old female with SOB and Anasarca. She has oliguria for the past 3 days. Vomiting and loose stools 5 days ago and subsided. History of SOB since 15 years and 10 to 15 episodes a year. 2 months ago pnemonitis with type 1 respiratory failure. On examination elevated blood Urea is seen along with Serum creatinine. SpO2 reduced to 80% in room air.

Provisional diagnosis - Left ventricular failure causing reduced ejection fraction secondary to CRF 

Complaints and problems 

Shortness if breath


Solution

Beta blockers given to help with the congestive heart failure and elevates the Shortness of breath




F)Patients with AKI :

1)https://keerthireddy42.blogspot.com/2021/07/43-yr-old-male-of-nalgonda-came-to.html?m=1

This is a case of a 43 year old male with complaints of loose stools for 20 days and pedal edema with abdominal distension. Chronic alcohol intake is seen and history of jaundice, 2 years ago. Palor is seen but icteris is absent.

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


Complaints and problems 

Pedal edema 

Abdominal distension 

Jaundice 


Solution 

Diuretics given for pedal edema.

For jaundice the patient was asked to stop alcohol and thiamine injection was given.



2)https://casescape.blogspot.com/2021/06/acute-kidney-injury-secondary-to.html?m=1

This is a case of a 60 year old with chief complaints of pedal edema since 10 days with high grade fever and oligurea. The patient was diagnosed with DM2 5 years ago. In 2019 she was diagnosed with AKI and secondary urosepsis and resolved with dialysis. Burning mituration seen along with oligurea. Occasional alcohol consumption. Pallor is seen but no icteris. High BP is seen with 170/110 mm hg. 

Provisional diagnosis Acute kidney injury secondary to urosepsis with hyperkalemia and anaemia 


Complaints and problems 

Acute kidney injury with urosepsis and burning mituration

Hyperkalemia

Anaemia 

Hypertension 


Solutions 

Iv fluids and diuretics given for AKI and urosepsis 

NSAIDs for pain 

Anti hypertensives 


3)http://chavvaclassworkdecjan.blogspot.com/2021/06/pancreatitis-in-chronic-alcoholic-with.html?m=1

This is a case of a 31 year old male with abdominal pain since 1 week, epigastric pain, non radiating and relived upon sitting. Bilious vomitting since one week. Complains of SOB since 2 days. Patient hospitalised one week ago. Creatinine elevated to 7.6 after admission. Hard liquor since 4 years, regularly. Last intake of 360 ml one week ago. Chewing tobacco since 10 years. BP elevated. Sp o2 88% in normal air. GRBS normal. Slight tremors seen. Distension of abdomen seen with epigastric and hypogastric tenderness. 

Provisional diagnosis - Acute pancreatitis with associated AKI. Patient in alcohol withdrawal. 


Complains and problems 

Bilious vomitting 

SOB 

Creatinine elevated to 7.6. AKI 

Alcohol withdrawal 

Elevated BP 

Sp O2 


Solutions 

I/O charting for AKI

Hemodialysis for AKI 

CECT abdomen was done

Case is still on going, case log will be updated when further treatment is given




Question- 5

Experiences and advantages of logging ones own experiences


For the past 2 months we have been working on the e log which has involved peer review, self assessment and case sheet writing. This has given us a unique perspective by giving us a retrospective look at at case as compared to a current look given by most clinical methods. This helps us assess the prognosis of casses better and understand better why a certain method of treating was preferable and why a certain drug was used. It also allows us to analyse the mistakes made during the diagnosis and the treatment of the patient and the ramifications of misdiagnosis and late diagnosis. By maintaining a regular blog we are seeing the importance of the process and the structure maintained in a ward and how these processes and structures help in an efficient work and learning environment for both the doctors and the patients. The logs finally thought us the importance of learning and showed us how a doctor is always in the process of learning and the many ways they can continue to educate themselves. I'd like to thank Dr Rakesh for the opportunity to study with you and the team and these e logs have helped me a lot to improve my diagnostic knowledge in medicine 

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