Greetings to one and all going through my e log.
I am Saranya , A final year student of MBBS .
EXPECTATION FROM MY WORK :
Briefing you upon what you could expect in the upcoming scrolls.
This is basically an assignment which I had been given, a patient oriented one - for a monthly progress evaluation scheme .
Link to the Assignment : http://medicinedepartment.blogspot.com/2021/05/online-blended-bimonthly-assignment.html?m=1
I have improvised on it where i shall discuss about some cases ( patients adequately deidentified ) ,also analyse and reflect upon the deeper aspects of the pathology . We shall try to see things in a different light, not exactly in the classical question answer format,but in more of an open manner , so that there can be few more differentials that our grey mater would be stimulated to ponder about , and with which we can save one more life.
P.S : This piece of work may make you think that it has high proportion of pictures all throughout , but trust me the pictographical retention capacity is far higher ,'in medical terms , they induce more synaptic networks ☺
No wonder the fabulous Human brain saves memories in the form of "flashes " or "images "
So Lets Begin with the burning topic of the day..
COVID 19
What is the underlying pathology occuring at the level of the lungs ?
We have been always refering to the radiological findings in the patient of COVID 19 with terms such as " Ground Glass Opacities " or "Crazy Pavementing " but here I shall make an attempt to co-relate the actual pathology going on at the microscopic level with their visible radiological counterparts.
GROUND GLASS OPACITIES
The Pathology behind it :
Ref : https://ejrnm.springeropen.com/articles/10.1186/s43055-020-00355-3
The typical appearance of COVID-19 pneumonia is bilateral patchy areas of ground glass infiltration, more in the lower lobes. The appearance of other signs like consolidation, air bronchogram, crazy pavement appearance, and air bubble signs appear during the course of the disease.
Ground glass opacity (GGO) is the non-specific hazy opacification of the lung in the X-ray or computed tomography with no obliteration of bronchial or vascular markings. The presumed pathology include partial filling of the lung alveoli by fluid, interstitial thickening, or partial collapse of lung alveoli
They are heterogeneous, some micro area opacified whereas the adjacent micro area not so,and hence the picture is percieved of that of tiny pieces of ground glass.
The expert recommendations from the Chinese Medical Association Radiology Branch classified the CT manifestations according to the appearance of GGO into four stages
STAGING OF THE GGOs
STAGE I
The early stage is characterized by dilatation of capillaries and engorgement of vessels, mild fluid exudates in the alveoli, and interstitial edema, resulting in single or multiple patchy ground glass opacities. The ground glass opacities are mostly peripheral and subpleural.
STAGE II
The second stage is the one in which the lesions increase in density and size, forming mixed pattern of GGO and consolidation with or without air bronchogram. The cause of this appearance is the exudation into the alveolar space and the lung interstitium
STAGE III
The third severe stage in which there is fibrous exudates into the alveoli reflected in the chest CT as wide areas of consolidation with air bronchogram, with the non-consolidated area showing patchy ground glass infiltration
STAGE IV
In the 4th dissipation stage, the consolidation and ground glass infiltration gradually resolves, with small areas of residual fibrosis . In some cases, the diffuse ground glass infiltration may give the lungs a white lung appearance.
UPDATE
ATTENTION :Please note : The pictures used to depict the pathologies are not from my own experiences, they have been used from other institutions and journals who have worked on that area and published the same.
( Links to those works have been mentioned )
The credit completely goes to those organizations to have been able to bring up these amazing findings .
This is not an act of any copyright breach and I shall oblige to remove whatever seems objectionable to any of the respective authors.
CRAZY PAVEMENT SIGN :
The crazy paving signs represent thickened interlobular septa superimposed on GGO. This sign represents alveolar edema and interstitial inflammatory reaction
The crazy paving sign is a sign of progressive disease and its appearance may indicate that the disease is entering the peak stage , yet it is the first CT sign to resolve in the absorptive stage while the consolidation, and GGO may persist for up to 26 days .
What was found on performing Autopsy of COVID-19 infected Lungs :
Here we shall compare gross autopsy specimens and their respective histopathology findings too .
REFERENCE :
https://www.nature.com/articles/s41467-020-18854-2
https://journals.lww.com/co-pulmonarymedicine/fulltext/2021/05000/pulmonary_pathology_of_covid_19__a_review_of.8.aspx
A gene based study among a cohort of COVID patients published in The Lancet.
QUESTION 9
CASE DISCUSSION
Link : https://143vibhahegde.blogspot.com/2021/05/covid-in-26-yo-female.html
1. Why was this patient given noradrenaline?
The patient might have been moving into a sepsis induced hypotensive phase and hence ionotropic support was necessary to maintain optimal perfusion levels.
Also , Sepsis might have led to organ damage ..thus leading to AKI and in turn the blood pressure regulation by the kidneys also got deranged.
2. What is the reason behind testing for LDH levels in this patient?
Reference : https://erj.ersjournals.com/content/9/8/1736
https://erj.ersjournals.com/content/9/8/1736
Rationale of Lactate Dehydrogenase in this patient is that , it serves as indicators suggestive of disturbances of the cellular integrity induced by pathological conditions like inflammation. Since LDH is an enzyme present in essentially all major organ systems(intracellular enzyme ), note that serum LDH activity is abnormal in a large number of disorders.
3. What is the reason for switching from BiPAP to mechanical ventilation with intubation in this patient? What advantages did it provide?
BiPAP is a non invasive method of Ventilation which provides a positive pressure against the driving pressure such that the alveoli do not completely collapse which in turn facilitates air exchange , but when the body does not suffice with that as well ( indicated by falling saturations , hypoxic features ) we need to move forward with invasive forms of Ventilation ( intubation whereby in case of Endotracheal Intubation we can do away with some dead space .
P.S : This young girl was extremely brave indeed and held on to her strings of life till the last moments , there were times where the monitors would show very low saturations even with support , along with vivid clinical distress too, but when asked how she was feeling , she always answered positively , she kept the hope of getting back to her normal life
but Alas we lost her to Sepsis and Shock
PICTOGRAPHICAL EXPLANATIONS :
QUESTION 5B:
Link to the case e log :
1) Cause of liver abcess in this patient ?
The patient might have been running low in this constitutional nutrition stores , by nature his immune system might have been low , and unhygienic food and water intake which might have lead to the parasitic infestation in him which got disseminated into his liver via the portal system .
2) How do you approach this patient ?
HIstory and Clinical Evaluation is the most essential and needs to be done primarily.
Which is to be followed by liver profile ( blood works ) and various modalities of Imageology to be done.
3) Why do we treat here ; both amoebic and pyogenic liver abcess?
This is because they both are extremely close differentials to an extent of overlap ,hence better to treat proactively for both .
4) Is there a way to confirm the definitive diagnosis in this patient?
An ultrasound guided liver biopsy shall confirm our diagnosis when we actually visualize the anchovy sauce pus drooling out from the abcess.
PICTOGRAPHICAL EXPLANATIONS :
QUESTION 5B:
1.Why is the child excessively hyperactive without much of social etiquettes ?
Children in their developmental time , many a times seem to be different with regard to their behaviour when compared to the expected normal , these differences can range from deviated behaviour noted by their teachers in School , by parents and grandparents at home .
they can indicated towards
Autism
ADHD
Dyslexia and many more such disorders.
In this case , his hyperactivity , unattentiveness , over talkative nature and uninhibited ettiquetes might be pointing towards Attention Deficit Hyperactivity Disorder , but again because these disorders have very close /overlapping/variable presenting behavioural patterns we need more time to spend with child to be able to pin point at the diagnosis.
2. Why doesn't the child have the excessive urge of urination at night time ?
The ball rolls more towards an existence of a suppressed yet Generalized Anxiety Disorder or some yet-to-be-identified stressors playing subconsciously in the mind if the 8 year old and manifesting as hyperurination .
Maybe because he is asleep , those stressors are not triggered hence the absence of nocturia/enuresis .
Maybe having a Sleep Study in the patient would also help in determining the proportion of REM vs NREM phases , such that we can corelate whether or not he is in sound sleep or not.
3. How would you want to manage the patient to relieve him of his symptoms?
According to the history and the investigations that were carried out ( the urine examination , culture , complete hemogram , renal profile ) were found to be within physiological limits , and also going by the spectrum of behaviour present in him ( communicated by the mother )
I would be more inclined towards a psychological quotient playing in the forefront.
Hence the mode of management by counselling sessions and Cognitive Behavioural Therapies .
PICTOGRAPHICAL EXPLANATIONS :
NEPHROLOGY
QUESTION 4
(c)
Link to patient details:
1) What is the most probable diagnosis in this patient?
Could it be an extreme stage of a some maligancy which metastasized without any red signal ?
Resulting in the hemorrhagic aspirate and evident deterioration after the laparotomy .
The Kidney Injury could be an additive entity to it ,
Or maybe a hemorrhagic third space fluid accumulation due to a mass there , accompained by the kidney damage?
2) What was the cause of her death?
Looks like an internal bleed leading to a hypovolemic shock.
3) Does her NSAID abuse have something to do with her condition? How?
Yes, very much.
I shall explain the mechanism pictographically-
PICTOGRAPHICAL EXPLANATIONS :
QUESTION 10
My experience in dealing with patients via Tele Medicine :
The Pandemic may be for the first time compelled medical students to stay back at home for months together during their course of MBBS.
During the second wave of COVID ,which is still on at present , I got stuck up at home while being in the Final year of my MBBS course
A part of it I would like to bring light upon in this writing today.
Due to this pandemic ,as we know there are thousands of people infected with the deadly virus but not having the privilege of being checked upon by a doctor ,or of being alloted a bed and an oxygen cylinder in the vicinity
All these have now become more than known stuffs but
The other side of the sad story is that there are scores of other patients who do aren't suffering from COVID but this lockdown, and the scare of hospitals and clinics being infected , have prevented these people from getting even bare minimum of consultations for their varied other pathologies, be it a chronic or an acute one.
In such a scenario , telemedicine comes handy to such patients ,
I have been communicating with quite a few such individuals about whom I shall be discussing here
( Please Note : no details about the patient shall be delivered in this write up in order to preserve the privacy of the patients and their near ones )
MY TELEMEDICINE PATIENTS
(I shall give a brief outline of their stories )
The Young Boy whose Kidneys shut down
The briefing which I had recieved before interacting with the patient over the call was that he is eager on getting a liver transplant done,
So in my mind by default I expected the patient to be an aged individual combatting a chronic illness for years
But it turned out that the patient was just 21 years old !! With such severity of the disease that his urine output is an absolute zero unless and until gets a bout of hemodialysis every alternate day!
He hails from a severely poverty striken background where the mother is a house help in a couple of nearby villas, the father sells vegetables and his younger brother is still in school.
There is even more to the sad story
His parents have almost lost their little income amidst this pandemic
The History which I could extract during that conversation was that 2 years back he had had burning micturition, loin pain and had seen a local RMP who had asked him to get a urine examination done
He had got the test done ,and it seems he was told to have been harbouring good amount of urinary tract infection.
He had been prescribed medications and some further investigations too, but he couldn't afford any of them.
Two years later ,one fine day he began feeling very heavy along with difficult breathing
When rushed to a hospital ,he was told that both his kidneys had been damaged and that he would need to undergo dialysis for the rest of his life
Or else have a transplant
More to this story :
He does not have a donor in his family due to cross matching issues
Guess what his usual everyday B.P is like ?
A whooping 190/ 140 mm Hg.
Recently he also got diagnosed with Hepatitis C, and now he needs to buy his own dialysis kits every single time which has made the process even more uneconomical for him and his small,helpless family.
The old man with a refractory Anemia
Link to my elog about his case : https://drsaranyaroshni.blogspot.com/2021/05/a-65-year-old-man-with-cluster-of.html
This story is about a 65 year old man ,lives his life with his family in a far off village .
He had had the pathology of hemorrhoids around 6 years ago, got a surgery done for it ,which was successful
But never has any physician been able to correct his anemia.
We are yet to solve the maze to locate where exactly the problem lies.
Otherwise just for the sake of temporary treatment ,many a times he has been suggested transfusions,but even after the transfusions ,never has the deficit got corrected.
The Hyperactive 8 year old :
Under the guidance of Dr.Mahima ; a Clinical Psychologist by profession, we tried to counsel the mother regarding how she can try and bring about changes in the behaviour of her 8 year old ,
the mother also sent us some glipses of the child's handwriting and artworks which helps in narrowing down upon the diagnosis .
I shall attach a few of those images here :
handwriting
Some Artworks by him :
There have been many more such patients , some with progressively weakening limbs, some with unexplained rashes and so on.
Tele medicine has made me step into their shoes and understand what life is like with the disease or the diseased. It has somehow made me take ownership of these patients who expect some or the other help , they feel that we are able enough to heal them and that belief in the patient somehow pushes me to learn and improvise more.
An illness does not bring with itself physical agony only, it completely deranges the rhythm of life of the patient and also the near ones.
Some more of the Case Based Learning Process :
Question 1
Link to the case :
PICTOGRAPHICAL EXPLANATIONS :
QUESTION 2
PICTOGRAPHICAL EXPLANATIONS :
QUESTION :
LINK :
LINK :
PICTOGRAPHICAL EXPLANATIONS :
QUESTION :
LINK :
PICTOGRAPHICAL EXPLANATIONS :
QUESTION :
Link :
PICTOGRAPHICAL EXPLANATIONS :
QUESTION 3:
Link :
PICTOGRAPHICAL EXPLANATIONS :
Any reviews , comments, inputs , advice about the content or about the management is absolutely welcome since it would really feel great to have helped a patient via this piece of work.
Thanks &
Regards
Saranya