An apparently simple case but with a Twist

 

A TELEMEDICINE PATIENT CENTRED DOCUMENTATION

A note before we begin :

This is online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs .This e-log book also reflects my patient centered  online learning portfolio and your valuable comments on comment box is welcome.

What the readers can expect from this piece of document :

This case was a telemedicine based one whereby , I ( under the guidance of my teacher ) tried to converse, understand the problem being faced by the patient and advice her regarding the relieving measures ( while mentioning her to consult a physician or a nearby health care institution in case of emergency )

this is a CONVERSATIONAL E-LOG

i.e  I shall sequentially arrange the learning conversation that went on between the mentor and mentee..to project and highlight how one single patient can trigger thousands of learning possibilities and open up innumerable closed doors to lead to the pinnacle of knowledge.

DEIDENTIFICATION : Please note that the participants of the conversation have been deindentified

HP : Mentor

MN : Mentee

[10:09 AM, 7/1/2021] Mentor : Can any of our student members here take the details of a middle aged woman told to have a BP that is very low, pulse thready with borderline diabetes so that we can understand her current requirements and then advice her? 

A similar exercise was recently carried out in this group and archived here https://drsaranyaroshni.blogspot.com/2021/05/an-eight-year-old-with-frequent.html?m=1

Pm me for her phone number if anyone is interested in the above exercise of improving learning outcomes to drive real patient health outcomes

[10:09 AM, 7/1/2021] Mentor: 👆if you are planning to call her later she would prefer evening

[10:09 AM, 7/1/2021] Mentor: Some literate pateints can even be texted

[10:09 AM, 7/1/2021] Mentee: Ok sir

Will call her in the evening.

[10:09 AM, 7/1/2021] Mentee: Sir

The patient you had spoken to yesterday...

The referral  

She has bp of 110 /60

[10:09 AM, 7/1/2021] Mentor: Feedback from my friend (who is also her friend) 

"Spoke to the Dr student.  Thanx i felt better just speaking to her   "

Well done 👏

[10:09 AM, 7/1/2021] Mentor: Very well done audio as well as overall consultation. 

I think it will be a good idea to make some audio case reports (first time in the world?) and E log them to share them widely as learning insights into Telemedicine. Take a signed informed consent for it if possible although the patient is already perfectly deidentified here so it may not be necessary. You can even try audio visual consent taking as it would gel with the national bioethics research guidelines 

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5799953/

[10:09 AM, 7/1/2021] Mentee: Her blood pressure today is 104/72 mm Hg

[10:09 AM, 7/1/2021] Mentee: Sir 

I told her not to take antihypertensive meds today as well

Maybe we can start from tomorrow

[10:09 AM, 7/1/2021] Mentor: Ask her to monitor it regularly and take it only if it goes above 135/85 among the average of all her daily readings. 

Maybe she never needed the antihypertensives in the first place? How long has she been told to have hypertension?

[10:09 AM, 7/1/2021] Mentee: For the past 3 years sir

[10:09 AM, 7/1/2021] Mentor: Let's monitor and see. 

Maybe she never needed it

[10:09 AM, 7/1/2021] Mentee : Sir

Her b.p. is being somewhere around 120/70 mm Hg

[10:09 AM, 7/1/2021] Mentee: But it has been more than a week she is without her meds

[10:09 AM, 7/1/2021] Mentee: Should we start her on half dosage of what she used to have previously sir?

[10:09 AM, 7/1/2021] Mentor: Let's ask her to monitor and let us know how many times it's going above 140'/90.

She needs to monitor at least ten times a day at random intervals

[10:09 AM, 7/1/2021] Mentee: Ok sir

[10:09 AM, 7/1/2021] Mentee: She usually takes this antihypertensive combination sir( telmisartan + Chlorthalidone )

[10:09 AM, 7/1/2021] Mentor : The chlorthalidone can cause dangerous hyponatremia

[10:09 AM, 7/1/2021] Mentee: Yes sir!!

Even telmisartan proves to be too sensitive to many patients sir

Y not keep her on losartan twice daily?

[10:09 AM, 7/1/2021] Mentor: Anyway she is not that much of a hypertensive

[10:09 AM, 7/1/2021] Mentee And because of the long acting effect of Telma she is having these readings maybe

[10:09 AM, 7/1/2021] Mentee: And even after that if she needs titration we can add a beta blocker once daily

[10:09 AM, 7/1/2021] Mentee: That too she is on telmisartan 80 mg !!!

People get hypotensive phases with 40 mg itself sir!!

[10:09 AM, 7/1/2021] Mentee: That patient

[10:09 AM, 7/1/2021]  Mentee: Developed pedal edema as well

[10:09 AM, 7/1/2021] Mentee: Pitting type till the ankle

[10:09 AM, 7/1/2021] Mentee : I guess the chlorthalidone was helping her edema till now. 

Mentor :What may have been the cause for her edema? Hypoalbuminemia or heart failure or idiopathic edema of women?

[10:09 AM, 7/1/2021]Mentee:  We need to get investigations done for that..

[10:09 AM, 7/1/2021]Mentor: Before that can we have her history from earlier let's say from the time she first met a doctor and was detected hypertensive or even earlier from her childhood?

[10:09 AM, 7/1/2021]Mentee : Ok sir

[10:09 AM, 7/1/2021]  Mentee:Will talk to her today

[10:09 AM, 7/1/2021] Mentor: Chest X-ray 

Ecg 

Echocardiography 

(even in the past if available)

Video of her neck veins in the 90 degree sitting position 

Serum albumin (even in the past if available)

[10:09 AM, 7/1/2021] Mentee: Ok sir

Urea 

Creatinin?

[10:09 AM, 7/1/2021]Mentor: Any past report of complete hemogram

[10:09 AM, 7/1/2021] Mentor: Yes just creatinine will do

[10:09 AM, 7/1/2021] Mentee: Okkay sir

[10:09 AM, 7/1/2021] Mentee: Sir

[10:09 AM, 7/1/2021] Mentee: That patient

[10:09 AM, 7/1/2021] Mentee: She got dyspneic

[10:09 AM, 7/1/2021]  Mentee: Maybe coz of the fluid overload!

[10:09 AM, 7/1/2021] Mentee: She has a history of huge steroid intake

[10:09 AM, 7/1/2021] Mentee: To treat her psoriasis

From a naturopathy doctor

[10:09 AM, 7/1/2021] Mentor: Possible heart failure. 

Why was she on steroids?

[10:09 AM, 7/1/2021] Mentor: How do we know it was steroids as naturopath doctors are not supposed to be prescribing it

[10:09 AM, 7/1/2021] Mentee: I told her to resume her medicine

And in the mean time get the investigations done

[10:09 AM, 7/1/2021] Mentee: No sir

It's a long story

I will tell you completely ,give me some time sir

I ll talk to her some more

[10:09 AM, 7/1/2021] Mentor: Hope you asked her to remain in touch with a local physician in case of emergency

[10:09 AM, 7/1/2021] Mentor: When did she first notice her psoriasis? When did the tea company doctor first prescribe her medications for her ankle swelling? Was the dyspnoea noticed by her today for the first time?

[10:09 AM, 7/1/2021] Mentee: Ans 1.  3 years back

Ans 2. Around 2 back.

Ans 3. Today.

[10:09 AM, 7/1/2021] Mentee: *2 years

[10:09 AM, 7/1/2021] Mentor: No past history of asthma? 

What drugs did the previous doctor prescribe two years back? How long did she take them?

[10:09 AM, 7/1/2021] Mentee: Goodevening sir

Sir that lady...your colleague's acquaintance..

She has given her blood sample for investigation..

Reports awaited..

The technician has said after doing the ecg and 2D echo that all is fine it seems

Though official report and strip is awaited .

She had resumed taking her medication due to the fluid accumulation..edema..and SOB

But her b.p is low only sir ..

110/60 mm Hg on an average

Could u help me regarding what I should comment about her taking the meds and the existing low b.p

[10:09 AM, 7/1/2021] Mentor: 110/60 should be OK. 

She should just take care it doesn't fall below 80/50

[10:09 AM, 7/1/2021] Mentee: Sir

One more thing I wanted to share with you

Remember the patient who was your friend's friend..

The lady with low B.p ?

She used to send him her b.p.readings every morning..and update about her health and all

Once the topic of the locations of residences had come up

And then yesterday she sent me a cake which she had herself baked.

[10:09 AM, 7/1/2021] Mentee: I felt so humbled

I told her many times that her regard was enough ,the cake wasn't needed at all

But she had already baked and sent it

[10:09 AM, 7/1/2021] Mentor: Tell her to send healthy fruits and vegetables next time as cakes and all other baked products are unhealthy and possibly responsible for her hypertension and other NCDs that emerge from the visceral fat driven adipokines. 

[10:09 AM, 7/1/2021] Mentee: 

She is home baker sir.. she finds joy in baking.. maybe I ll make her sad if I tell her to stop her hobby :( but definitely I tell her not to consume her bakery products :)

[10:09 AM, 7/1/2021] Mentee: Sir

Thankyou for letting me have the opportunity to interact with my patients

To understand them

And to get all the love from them

[10:09 AM, 7/1/2021] Mentor: This is psychotherapeutic redirecting challenge. Take up this challenge with Mahima to redirect her cooking joy in a healthier direction?

[10:09 AM, 7/1/2021] Mentee: Will try sir.

A 27 year Old Male with Acute Abdominal Pain

 

EXPECTATION FROM THIS E LOG :

This is online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs .This e-log book also reflects my patient centered  online learning portfolio and your valuable comments on comment box is welcome.

I thank Dr. Chitra , for providing me with every detail about the patient , and also being extremely patient with my doubts about the case. 

Introduction : 

The Patient is a 27 year old Male , a Post Office Employee  in Telangana .

Chief Complaint :  

The Patient presented to the Casualty on 5th June 2021 with complaints of Pain in Upper Abdomen since the morning of that day.

History of Presenting Illness :

( Certain Past Events shall also be mentioned here , if they have a role in the present manifestation of the pathology )

The patient has been an Alcoholic since 5 years , with a daily intake of about 180 ml of Whiskey .

The Patient developed pain in the Upper Abdomen in the early morning hours of 5th June 2021 and was rushed to the hospital.

Pain was sudden in onset , rapidly progressing , aggravated ( burning sensation ) by spicy/heavy food intake , no relieving factors as such.

He described the pain to be diffuse , radiating to the back .

Not associated with

Nausea/ Vomiting

Shoulder Tip Pain

Distended Abdomen.

 

Last History of Alcohol Intake : 2nd June 2021

Past History :

No similar Complaints of Acute Abdominal Pain in the past,.

In 2014, he had had an acute attack of SOB,triggered by cold exposure , had got relieved on medication .

He was prescribed Inhalers but is not compliant to the same.

In 2015, he had an episode of Epilepsy , for which he is under medication .

He is not a K/C/O  DM , HTM , CAD .

Personal History :

Appetite is normal ,

Takes Mixed Diet,

Bowel and Bladder : Normal

Sleep : Adequate

Does not Smoke

Is a Regular Alcoholic since 5 years ( details mentioned above )

No known food or drug allergies .

He is less tolerant to cold exposure / cold food/drinks . (Asthma Trigger )

Family History : 

Not Significant.

Treatment History :

  Has had a Surgical repair for Inguinal Hernia 4 years ago.

NOTES : 

EXAMINATION :

GENERAL EXAMINATION :

The patient was examined in both sitting and supine position  after obtaining Consent . Examination was done in a well lit room , in the presence of an attendant , with adequate exposure .

Patient in Pain .Wincing Expression . ( Wong Baker's Rating : 8 ) .

Patient is not still on bed.

The patient is of moderate nutrition and built. 

TRUNCAL OBESITY PRESENT.

Conscious , Coherent , Cooperative . Oriented to time , place and person.

He does not have

Pallor, Icterus , Cyanosis , Koilonychia , Clubbing ,Generalised Lymphadenopathy ,Pedal Edema.

VITALS on Presentation :

Pulse : 110 bpm , normal Rythm , volume , condition of vessel wall , without any delay.

B.p :   130 / 80 mm Hg recorded in the Right Brachial Artery in supine position

R.R : 22 cpm

Body Temp. : Afebrile .

SpO2 : 98 % on r.a.

Pain : Present , Rating 8 ( Wong Bakers Rating ).

SYSTEMIC EXAMINATION :

CVS : normal


RESPIRATORY SYSTEM : normal


CNS : normal


ABDOMEN :  Abdomen soft , tender.

Note : Tender Abdomen .Abdomen is distension has increased . On 6/June/2021 night : Resonant note was obtained up to 3 cm above the umblicus but

On 7/jun/2021 morning : Resonant notes percieved till below the umblicus.

Shifting Dullness present .

INVESTIGATIONS :

Complete Blood Count

Urine Sample 

COMPLETE URINE EXAMINATION

COAGULATION PROFILE :

LDH raised

SERUM LIPASE raised

SERUM AMYLASE raised

Normal Random Blood GLucose

LFT

RFT and ELECTROLYES

CHEST RADIOGRAPH

RYLE'S TUBE ASPIRATE.

FEVER CHART

ULTRASONOGRAPHY REPORT

CROSS CONSULTATION NOTES : 

Provisional Diagnosis : A 27 year old man , chronic alcoholic with acute pancreatitis and Grade II Steatohepatitis .

INTERVENTIONS DONE :

Plan of Management : Conservative.

Communication with Attenders :  Outcome has been adequately explained .

Medications :

UPDATED : ( 9th June 2021 )

             

i

A Case of COVID 19 Pneumonia

 Introduction :  

This is online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs .This e-log book also reflects my patient centered  online learning portfolio and your valuable comments on comment box is welcome.

Regards to Dr. Anjali who has guided me and provided me with the information about the patient.

An Outline about the Patient : 

He is a 51 year old gentleman from a village in South India.

Chief Complaints : The Patient presented on 1/06/2021 with Cough since 6 days , Chest Pain since 4 days

History of Presenting Illness :  

The patient was apparently asymptomatic 6 days back when he developed Cough ( wet )  .It was insideous in onset . The expectoration was minimal in amount , mucoid in consistency , non foul smelling , non blood stained . Not aggravated or relieved with posture.

He developed Chest pain 4 days back , sharp in nature , not radiating to back , or upper limb . Pain aggravated on respiration movements of the chest and on coughing as well , no relieving factors as such.

COVID RTPCR done at the hospital on 3/6/21 and  positive results obtained.

There is no History of 

Shortness of Breath

Hemoptysis

Fever

Body Pains

Fatigue

PAST HISTORY :

  History of  previous infection with COVID 19 on 13/05/21 , for which he had been hospitalized and was given O2 Support for 5 days before his discharge on the 6th Day.

He is a K/C/O  DM, ( Since 9 years , takes Glimiperide 2mg , Metformin 500 mg BD )

HTN ( Since 3 years , takes Amlodipine 5 mg O.D )

No past H/o CAD , Asthma , Epilepsy .

PERSONAL HISTORY :

He has normal appetite ,

Takes Mixed Diet

Sleep slightly disturbed due to Cough 

Constipation since the last 5 days.

Not an alcoholic.

Used to Smoke but stopped 12 years back. 

No known Allergies.

Family History : 

Contacts being traced for any COVID  infected indivual ( if any ). 

GENERAL EXAMINATION : 

Done after obtaining consent , in a well lit room , in the presence of an attendant , with adequate exposure .

No pallor , Icterus , Cyanosis , Clubbing , Koilonychia , Generalised Lymphadenopathy or Pedal Edema.

 

VITALS  : 

RADIOLOGICAL INVESTIGATIONS : 

ECG :

REPORTS :  

MONITOR READING :  

PROVISIONAL DIAGNOSIS :

UPDATE :
7/JUNE/2021

Patient Discharged 

 

Assignment : A Patient Centred Learning Process

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 :

https://63konakanchihyndavi.blogspot.com/2021/05/case-discussion-on-liver-abcess.html

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:

https://drsaranyaroshni.blogspot.com/2021/05/an-eight-year-old-with-frequent.html

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:

https://chennabhavana.blogspot.com/2021/05/general-medicine-case-discussion-1.html

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 :

Link :  https://drsaranyaroshni.blogspot.com/2021/05/an-eight-year-old-with-frequent.html

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 :  

https://soumyanadella128eloggm.blogspot.com/2021/05/a-55-year-old-female-with-shortness-of.html

PICTOGRAPHICAL EXPLANATIONS :

QUESTION 2

Link :  https://143vibhahegde.blogspot.com/2021/05/wernickes-encephalopathy.html

PICTOGRAPHICAL EXPLANATIONS :

QUESTION :
LINK :

https://kausalyavarma.blogspot.com/2021/05/a-52-year-old-male-with-cerebellar.html?m=1

PICTOGRAPHICAL EXPLANATIONS :

QUESTION :

LINK :

http://bejugamomnivasguptha.blogspot.com/2021/05/a-45-years-old-female-patient-with.html

PICTOGRAPHICAL EXPLANATIONS :

QUESTION :

Link :

https://rishikoundinya.blogspot.com/2021/05/55years-old-patient-with-seizures.html

PICTOGRAPHICAL EXPLANATIONS :

QUESTION 3:

Link :

https://muskaangoyal.blogspot.com/2021/05/a-78year-old-male-with-shortness-of.html.

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