Online blended bimonthly assignment for the month of May 2021

 

I have been given the following cases to solve in an 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 and come up with a treatment plan.

This is the link of the questions asked regarding the cases:

 

Below are my answers to the Medicine Assignment based on my comprehension of the cases. 

1) Pulmonology (10 Marks) 

 

A) 

   " A 55 Year Old Female with Shortness of Breath, pedal Edema and Facial              Puffiness."

 

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

 

Questions:

 

1) What is the evolution of the symptomatology in this patient in terms of an event timeline and where is the anatomical localization for the problem and what is the primary etiology of the patient's problem?

 

Ans:   EVOLUTION OF SYMPTOMATOLOGY

         1st episode of SOB --20 years back

         2nd episode of SOB --12 years back

         From then she has been having yearly episodes for past 12 years

         Then she diagnosed with diabetes 8 years back 

         she is anemic and took IM injections 5 years back 

         generalized weakness since 1 month 

         diagnosed with hypertension 20 days back 

         pedal edema 15 days back 

         facial puffiness 15 days back 

         

        ANATOMICAL LOCATION OF PROBLEM

         Lungs 

         PRIMARY ETIOLOGY OF PATIENT PROBLEM

         Usage of chulha since 20 years 

         Might be due to chronic dosage 

          

2) What are mechanism of action, indication and efficacy over placebo of each of the pharmacological and non pharmacological interventions used for this patient?

 Ans: Head end elevation:

          MOA-improves oxygenation 

                    decreases incidence of VAP

                     increases hemodynamic performance 

                     increases end expiratory lung volume 

                     decreases incidence of aspiration 

          INDICATIONS-head injury 

                                  meningitis 

                                  pneumonia 

          O2 inhalation to maintain spo2 

          Bipap : non invasive method 

          MOA- Assist ventilation by delivering positive expiratory and inspiratory pressure with out need of ET        intubation                         

 

3) What could be the causes for her current acute exacerbation?

Ans: may be due to any infection 

 

4. Could the ATT have affected her symptoms? If so how?

Ans :YES,

         ATT affected her symptoms .Isoniazid and Rifampcin which are nephrotoxic which causes raised RFT

 

5.What could be the causes for her electrolyte imbalance?

Ans: ATT could have caused  renal damage which lead to her electrolyte imbalance

 

 

2) Neurology (10 Marks) 

A)   

       "  A 40 Year Old Male with Complaints of Irrelevant Talking"

 

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

 

Questions:

 

1) What is the evolution of the symptomatology in this patient in terms of an event timeline and where is the anatomical localization for the problem and what is the primary etiology of the patient's problem?

 

Ans :   EVOLUTION OF SYMPTOMATOLOGY 

 

2009 (12 years ago): Started drinking alcohol

 

2019 (2 years ago): Diagnosed with Diabetes Mellitus, prescribed oral hypoglycemics

 

2020 (1 year ago): Has an episode of seizures (most likely GTCS)

 

January 2021 (4months ago): Has another seizure episode (most likely GTCS)- following cessation of alcohol for 24 hours. Starts drinking again after seizure subsides

 

Monday, May 10, 2021: Last alcohol intake, around 1 bottle. Starts having general body pains at night.

 

Tuesday, May 11, 2021: Decreased food intake. Starts talking and laughing to himself. Unable to lift himself off the bed, help required. 

 Conscious, but non coherent. Disoriented to time, person, place. 

 Goes to an RMP the same day- is prescribed IV fluids and asked to visit a hospital

 

Saturday, May 15, 2021: Is admitted to a tertiary care hospital for alcohol withdrawal symptoms, and is treated for the same.

 

 

ANATOMICAL LOCATION OF PROBLEM: The most probable location in the brain is the hippocampus and frontal lobe.

 

PRIMARY ETIOLOGY OF PATIENT PROBLEM: Chronic Alcoholism

 

 




2) What are mechanism of action, indication and efficacy over placebo of each of the pharmacological and non pharmacological interventions used for this patient?

 Ans:  pharmacological intervention:

  1.Thiamine
mechanism of action :thiamine prevents occurrence of Wernicke encephalopathy which occurs due to deficiency of thiamine I 
 indications : treatment of beri beri
                       Neuritis
                       Ulcerative colitis 
                       to prevent Wernicke encephalopathy
efficacy: Background: Alcohol dependence is associated with severe nutritional and vitamin deficiency. Vitamin B1 (thiamine) deficiency erodes neurological pathways that may influence the ability to drink in moderation. The present study examines tolerability of supplementation using the high-potency thiamine analogue, benfotiamine (BF), and BF’s effects on alcohol consumption in severely affected, self-identified, alcohol dependent subjects. Methods

randomized, double-blind, placebo-controlled trial was conducted on 120 non-treatment seeking, actively drinking, alcohol dependent men and women volunteers (mean age=47 years) from the Kansas City area who met DSM-IV-TR criteria current alcohol dependence. Subjects were randomized to receive 600 mg benfotiamine or placebo (PL) once daily by mouth for 24 weeks with 6 follow-up assessments scheduled at 4 week intervals. Side effects and daily alcohol consumption were recorded. Results Seventy (58%) subjects completed 24 weeks of study (N=21 women; N=49 men) with overall completion rates of 55% (N=33) for PL and 63% (N=37) for BF groups. No significant adverse events were noted and alcohol consumption decreased significantly for both treatment groups. Alcohol consumption decreased from baseline levels for 9 of 10 BF treated women after 1 month of treatment compared with 2 of 11 on PL. Reductions in total alcohol consumption over 6 months were significantly greater for BF treated women (BF: N=10, −611±380 Std. Dev; PL: N=11, −159±562 Std. Dev, p-value=0.02). ConclusionsBF supplementation of actively drinking alcohol dependent men and women was well-tolerated and may discourage alcohol consumption among women. The results do support expanded studies of BF treatment in alcoholism.

 2.lorazepam and pregabalin are given for the neurological symptoms. Benzodiazepines

Benzodiazepines (BZD) are the mainstay of treatment in alcohol withdrawal. Benzodiazepines are safe, effective and the preferred treatment for AWS. Benzodiazepines are cross-tolerant with alcohol and modulate anxiolysis by stimulating GABA-A receptors  During withdrawal from one agent, the other may serve as a substitute. They are proven to reduce withdrawal severity and incidence of both seizures and delirium tremens (DT)

The ideal drug for alcohol withdrawal should have a rapid onset and a long duration of action, a wide margin of safety, a metabolism not dependent on liver function, and absence of abuse potential  Various BZDs offer many of these advantages. BZDs have been found effective in: 1) preventing agitation and alcohol withdrawal seizures; 2) preventing delirium tremens; and 3) as cross-tolerant agents with ethanol. BZDs, owing to their wide margin of safety and low potential to produce physical dependence and tolerance in short-course therapy, are therefore very, effective in the treatment of alcohol-withdrawal syndrome. They are the drugs of choice for alcohol withdrawal 

3.PREGABALIN

Mechanism of action:it is analog of neurotransmitter GABA

Indications:-peripheral neuropathic paint like diabetic neuropathy and post hermetic neuropathy

                   - adjuvant treatment of partial seizures

                   - management of fibromyalgia 

Efficacy of pregabalin

https://pubmed.ncbi.nlm.nih.gov/18553183/

 

3) Why have neurological symptoms appeared this time, that were absent during withdrawal earlier? What could be a possible cause for this?

 

Ans:  


A possible cause for this is due to a phenomenon known as kindling. 

 

In kindling, repeated attempted alcohol detoxification leads to an increased severity of the withdrawal syndrome. Patients with previous withdrawal symptoms are more likely to have more medically complicated withdrawal symptoms with time. 

 eg, in this patient 

Chronic alcohol use and kindling together leads to permanent alteration in GABA receptors, leading to downregulation of GABA. This in turn leads to inhibition of inhibitory neurotransmitter GABA, hence leading to seizures (hyperactivity).

 

4) What is the reason for giving thiamine in this patient?

 

Ans: 

One of the differential diagnoses for altered sensorium following chronic alcoholism is Wernicke-Korsakoff Syndrome, caused by deficiency of thiamine (B1). To either treat or rule this differential out, thiamine is given.

 

Thiamine is necessary to provide energy to the CNS, helps in conduction of nerve signals.

Hence, deficiency leads to confusion and ataxia, both of which are present in this patient.

 

5) What is the probable reason for kidney injury in this patient? 

 

Ans: 

As the urea levels are very high, it denotes an acute onset- Acute Renal Failure.

 

As high serum creatinine, and urea levels are present, denotes that reabsorption from tubules is taking place- therefore the primary cause is prerenal, most probably due to generalised dehydration.

 

A slightly high FENa level also denotes that tubular necrosis is occurring to some degree, hence the Prerenal AKI (mostly due to dehydration) is in turn leading to Acute Tubular Necrosis (ATN)

 

6). What is the probable cause for the normocytic anemia?

 

Ans : 

 Possible causes:

a. Increased oxidative stress and inflammation, leading to hemolysis of the RBCs

b. Decreased bone marrow production of RBCs, due to EPO deficiency owing to kidney failure

c. Loss of blood through chronic foot ulcer



 

7) Could chronic alcoholism have aggravated the foot ulcer formation? If yes, how and why?

 

Ans :

Yes, as alcoholism itself can cause peripheral neuropathy (alcoholic neuropathy), which along with Diabetic neuropathy, can lead to a non-healing foot ulcer.

 

B)  

A 52 year old male with Cerebellar Ataxia

 

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

 

Questions-

 

1) What is the evolution of the symptomatology in this patient in terms of an event timeline and where is the anatomical localization for the problem and what is the primary etiology of the patient's problem?

 Ans: symptomatology :patient gave history of giddiness 7 days back with one episode of vomiting which was subsided on taking rest.

       again 4 days after he developed giddiness which was associated with 2-3 episodes of vomiting, bilateral hearing loss, aural fullness and tinnitus.
       there is also history of postural instability.
    

2) What are mechanism of action, indication and efficacy over placebo of each of the pharmacological and non pharmacological interventions used for this patient?

 Ans: pharmacological interventions:

 1.VERTIN ;
Mechanism of action: It is a histamine analog ,it works by increasing blood flow in inner ear. 
IndicationsDizziness, vertigo, nausea and vomiting due to motion sickness
   Efficacy: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1808-86942011000400014   2.ZOFER Mechanism of action: It is an antiemetic.
        Indications: Nausea and vomiting following any surgery/chemotherapy/radiotherapy.
 
 3.ECOSPRIN 
Mechanism of action: IT is  a NSAID which has anti-platelet effect it prevents clot formation and thus prevents recurrence of stoke. 
INdication:As a part of treatment of stroke, as a prophylactic measure in previous stroke patients, angina. Efficacy:https://www.webmd.com/stroke/news/20000601/aspirin-after-stroke-helps-prevent-another

  4.ATORVOSTATIN mechanism of action :it is a statin which controls the levels of cholesterol in the body thus decreasing the atherogenesis and preventing stroke.
Indications: -dyslipidemias
                     After stroke to prevent recurrence.

   5.CLOPIDOGREL
Mechanism of action: it is also an anti-platelet drug, it is inhibitor of platelet activation and aggregation
Indications: IN symptomatic carotid artery stenosis, primary prevention of thromboembolism in atrial fibrillation, during PCI for ACS.

 

3) Did the patients history of denovo HTN contribute to his current condition?

 Ans:  Yes, HYPERTENSION IS A RISK FACTOR FOR STROKE.

4) Does the patients history of alcoholism make him more susceptible to ischaemic or haemorrhagic type of stroke?

 Ans: Even alcohol is also a risk factor for stroke.




C) 

A 45 YEARS OLD FEMALE PATIENT WITH PALPITATIONS, PEDAL EDEMA, CHEST PAIN,CHEST HEAVINESS,RADIATING PAIN ALONG LEFT UPPER LIMB

 

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

 

 

Questions:

 

 

1) What is the evolution of the symptomatology in this patient in terms of an event timeline and where is the anatomical localization for the problem and what is the primary etiology of the patient's problem?

 Ans: -patient developed bilateral pedal edema 8 months back which is present in both sitting and standing position

-she has pain since 6 days radiating to left limb which was dragging in nature.
-she also had palpitations since 5 days . chest pain and heaviness is also present.

2) What are the reasons for recurrence of hypokalemia in her? Important risk factors for her hypokalemia?

 Ans: as the patient do not have diarrhea or vomiting may be inadequate dietary intake or excess loss through kidney can cause recurrent hypokalemia. the patient also has pedal edema which can be suggestive of kidney malfunctioning.


3) What are the changes seen in ECG in case of hypokalemia and associated symptoms?

 Ans:  ECG changes in hypokalemia include inversion of T wave, QT interval prolongation, visible U wave and mild ST depression .if there is severe hypokalemia arrhythmias like Torsades de points and ventricular tachycardia.




55years old patient with seizures

 

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

 

 

QUESTIONS:

 

 

1. Is there any relationship between occurrence of seizure to brain stroke. If yes what is the mechanism behind it?

 Ans: Yes. 



 

2. In the previous episodes of seizures, patient didn't loose his consciousness but in the recent episode he lost his consciousness what might be the reason?

 Ans: The previous episodes can be caused only due to increased electrical activity ,in present episode there is associated CVA.

 

E) 

A 48 year old male with seizures and altered sensorium

 

https://nikhilasampathkumar.blogspot.com/2021/05/a-48-year-old-male-with-seizures-and.html?m=1

 

 

Questions: 1) What could have been the reason for this patient to develop ataxia in the past 1 year?

 Ans:  

Damage from alcohol is a common cause of cerebellar ataxia. In patients with alcohol related ataxia, the symptoms affect gait (walking) and lower limbs more than arms and speech.So alcohol may be reason for his ataxia 

.https://publicdocuments.sth.nhs.uk/pil3307.pdf


2) What was the reason for his IC bleed? Does Alcoholism contribute to bleeding diatheses ?

 Ans:   Liver damage due to too much alcohol can stop the liver from synthesis of coagulants              this may be the reason for his IC bleed

     https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1341444/#:~:text=The%20impaired%20platelet%20function%2C%20together,associated%20with%20excessive%20alcohol%20intake.

 

F)  

   " A 30 YR OLD MALE PATIENT WITH WEAKNESS OF RIGHT UPPER LIMB AND      LOWERLIMB"

 

http://shivanireddymedicalcasediscussion.blogspot.com/2021/05/a-30-yr-old-male-patient-with-weakness.html

 

Questions

 

1.Does the patient's  history of road traffic accident have any role in his present condition?

 

Ans: yes

      after trauma there may be tear in the head or neck blood vessels that leads to brain which can be             source of bloodclots that may cause stroke 

 

2.What are warning signs of CVA?

Ans ;

     Sudden numbness or weakness in the face, arm, or leg, especially on one side of the body.

     Sudden confusion, trouble speaking, or difficulty understanding speech.

     Sudden trouble seeing in one or both eyes.

     Sudden trouble walking, dizziness, loss of balance, or lack of coordination.



 

3.What is the drug rationale in CVA?

 

Ans:

      Aspirin -antiplatlet drug prevents stroke

      Atorvostatin - decreases LDL cholesterol to prevent recurrent attacks of stroke

 

4. Does alcohol has any role in his attack?

 

Ans:

Excessive alcohol consumption has been associated with a wide range of medical conditions. Moderate alcohol consumption is linked to a lower risk of stroke than abstinence, whereas heavy alcohol consumption has been associated with an increased risk of stroke and stroke mortality. In addition to alcohol consumption, the most important risk factors for stroke are hypertension, coronary artery disease, cardiac insufficiency, atrial fibrillation, type 2 diabetes, smoking, overweight, asymptomatic carotid artery stenosis and elevated levels of cholesterol.

 

5.Does his lipid profile has any role for his attack??

 

Ans: 

Yes increased LDL causes atherosclerosis -Blood vessels - ischemia leads to - stroke

 

G) 

   "A 50 YEAR OLD PATIENT WITH CERVICAL MYELOPATHY"

 

 

https://amishajaiswal03eloggm.blogspot.com/2021/05/a-50-year-old-patient-with-cervical.html

 

 

__*Questions*_

 

1)What is myelopathy hand ?

Ans :

   There is loss of power of adduction and extension of ulnar 2/3 fingers and inability to  grip and                release rapidity with these fingers is called myelopathy hand

 






                                                 right hand - myelopathy hand

               

2)What is finger escape ?

 

 Ans :

 

 Wartenberg's sign is a neurological sign consisting of involuntary abduction of the fifth (little) finger, caused by unopposed action of the extensor digiti minimi. ... This finding of weak finger adduction in cervical myelopathy is also called the "finger escape sign".



  



3)What is Hoffman’s reflex?

Ans ;  

   Hoffman's sign or reflex is a test that doctors use to examine the reflexes of the upper extremities. This test is a quick, equipment-free way to test for the possible existence of spinal cord compression from a lesion on the spinal cord or another underlying nerve condition

   A positive Hoffman sign indicates an upper motor neuron lesion and corticospinal pathway dysfunction likely due to cervical cord compression. However, up to 3% of the population has been found to have a positive Hoffman without cord compression or upper motor neuron disease


 

 

H) 

           "A 17 year old female  with seizures "

 

 

https://neerajareddysingur.blogspot.com/2021/05/general-medicine-case-discussion.html?m=1                  

 

  

 questions: 

 

              

1) What can be  the cause of her condition ?                             

Ans :

    According to MRI ,

                cortical vein thrombosis might be the cause of her seizures

 

2) What are the risk factors for cortical vein thrombosis?

Ans :

   Infections:

Meningitis, otitis,mastoiditis

Prothrombotic states:

Pregnancy, puerperium,antithrombin deficiency proteinc and protein s deficiency,Hormone replacement therapy.

Mechanical:

Head trauma,lumbar puncture

Inflammatory:

SLE,sarcoidosis,Inflammatory bowel disease. 

Malignancy.

Dehydration 

Nephrotic syndrome 

Drugs:

Oral contraceptives,steroids,Inhibitors of angiogenesis

Chemotherapy:Cyclosporine and l asparginase

Hematological:

Myeloproliferative Malignancies

Primary and secondary polycythemia

Intracranial :

Dural fistula, 

Vasculitis:

Behcets disease wegeners granulomatosis

 

3)There was seizure free period in between but again sudden episode of GTCS why?resolved spontaneously  why?                           

Ans : 

 Seizures are resolved and seizure free period got achieved after medical intervention but sudden episode of seizure was may be due to any persistence of excitable foci by abnormal firing of neurons.             

4) What drug was used in suspicion of cortical venous sinus thrombosis?

Ans :

   Anticoagulants are used for the prevention of harmful blood clots.

Clexane  ( enoxaparin)  low molecular weight heparin binds and potentiates antithrombin three a serine protease Inhibitor  to form complex and irreversibly inactivates factor xa.  

 

3) Cardiology (10 Marks) 

 

A) Link to patient details:

 

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

 

 

1.What is the difference btw heart failure with preserved ejection fraction and with reduced ejection fraction?

 Ans: Preserved ejection also known as diastolic heart failure where as reduced ejection fraction heart failure is known as systolic heart failure.



2.Why haven't we done pericardiocenetis in this pateint?        

 Ans: Here the patient only has acute pericarditis where the effusion is less than that of a tamponade ,the 2D echo suggests absence of tamponade so pericardiocentesis is not done.     


             




3.What are the risk factors for development of heart failure in the patient?

 Ans: Pericardium looses its elasticity in pericarditis and becomes rigid over time, so it does not transfer the intrathoracic pressure changes to the heart there by resulting heart failure.

4.What could be the cause for hypotension in this patient?

 Ans: Heart failure can be cause of hypotension in this patient.


 

B) Link to patient details:

 

https://muskaangoyal.blogspot.com/2021/05/a-73-year-old-male-patient-with-pedal.html

 

 

Questions:

 

1.What are the possible causes for heart failure in this patient?

 Ans:  Chronic hypertension can be the cause of heart failure in this patient.


2.what is the reason for anaemia in this case?

 Ans: Anemia is considered to be frequent comorbidity of heart failure.


3.What is the reason for blebs and non healing ulcer in the legs of this patient?

 Ans: The cause for nonhealing ulcer is diabetes (hyperglycemia impairs the healing process)


4. What sequence of stages of diabetes has been noted in this patient?

 Ans: Diabetes leading to macrovascular complication in the form of foot ulcer.

 

C) Link to patient details:

 

 

https://preityarlagadda.blogspot.com/2021/05/biatrial-thrombus-in-52yr-old-male.html

 

1) What is the evolution of the symptomatology in this patient in terms of an event timeline and where is the anatomical localization for the problem and what is the primary etiology of the patient's problem?

 Ans: the patient presented with short ness of breath which progressed from grade 2 to grade 4 

     -patient also complained of oliguria since two days and anuria since morning.

2) What are mechanism of action, indication and efficacy over placebo of each of the pharmacological and non pharmacological interventions used for this patient?

 Ans: 1.DOBUTAMINE 

mechanism of action: It is an inotropic drug 
Indications: cardiogenic shock, severe congestive cardiac        failure, hypo perfusion if associated with increased peripheral vascular resistance.

      2.UNFRACTIONED HEPARIN 
:mechanism of action: it inactivates thrombin and factor X through an antithrombin dependent mechanism. 
Indications: atrial fibrillation with embolization ,treatment of acute and chronic consumptive coagulopathies like DIC , prophylaxis and treatment of venous thromboembolism, prevention of clotting in arterial and cardiac surgery. 

      3.CARVEDILOL 
Mechanism of action;  it is a non selective adrenergic blocker 
Indication: heart failure with reduced ejection fraction, hypertension, left ventricular dysfunction following MI.

      4.ACETYLE CYSTEIN 
Mechanism of action:It increases the synthesis of glutathione in liver , glutathione acts as an antioxidant 
Indication:it is used in paracetamol overdosing, to relive chest congestion due to thickened mucous in cystic fibrosis, asthma, bronchitis.

3) What is the pathogenesis of renal involvement due to heart failure (cardio renal syndrome)? Which type of cardio renal syndrome is this patient? 

 Ans: 

  • TYPE 4 CRS is seen in this patient.

4) What are the risk factors for atherosclerosis in this patient?

 Ans:Hypertension accelerates the process of atherogenesis.


5) Why was the patient asked to get those APTT, INR tests for review?

 Ans:INR is used to determine the effect of oral anticoagulants

       aptt test is done to know how well the clotting factors are working.

D) Link to patient details:

 

https://daddalavineeshachowdary.blogspot.com/2021/05/67-year-old-patient-with-acute-coronary.html?m=1

 

 

Questions-

 

1) What is the evolution of the symptomatology in this patient in terms of an event timeline and where is the anatomical localization for the problem and what is the primary etiology of the patient's problem?

 Ans:  EVOLUTION OF SYMTOMATOLOGY

Diabetes since 12 years

 heart burn like episodes since 1 year but it relieved 

pulmonary TB 7 months back --treatment took now she is sputum negative 

hypertension since 6 months --on medications

 SOB since half an hour on day of admission to hospital

ANATOMICAL LOCATION OF PROBLEM:  Cardio vascular system


PRIMARY ETIOLOGY OF PATIENT PROBLEM:  atherosclerosis --plague formation [hypertension+ diabetes]


2) What are mechanism of action, indication and efficacy over placebo of each of the pharmacological and non pharmacological interventions used for this patient?

 Ans:   Pharmacological interventions:


TAB MET XL 25 MG/STAT-contains Metoprolol as active ingredient

 MOA:

 METOPROLOL is a cardiselective beta blocker

 Beta blockers work by blocking the effects of the hormone epinephrine, also known as adrenaline. Beta blockers cause your heart to beat more slowly( negative chronotropic effect)

and with less force( negative inotropic effect). Beta blockers also help open up your veins and arteries to improve blood flow.


Indications:

 it is used to treat Angina, High blood pressure and to lower the risk of hear attacks .


EFFICACY STUDIES:

Patients were randomized to one of four treatment arms: placebo or ER metoprolol (0.2 mg/kg, 1.0 mg/kg, or 2.0 mg/kg). Data were analyzed on 140 intent-to-treat patients. 


Outcome : 

 mean baseline BP was 132/78 +/- 9/9 mmHg. Following 4 weeks of treatment, mean changes in sitting BP were: placebo = -1.9/-2.1 mmHg; ER metoprolol 0.2 mg/kg = -5.2/-3.1 mmHg; 1.0 mg/kg = -7.7/-4.9 mmHg; 2.0 mg/kg = -6.3/-7.5 mmHg. Compared with placebo, ER metoprolol significantly reduced systolic blood pressure (SBP) at the 1.0 and 2.0 mg/kg dose (P = .027 and P = .049, respectively), reduced diastolic blood pressure (DBP) at the 2.0 mg/kg dose (P = .017), and showed a statistically significant dose response relationship for the placebo-corrected change in DBP from baseline. There were no serious adverse events or adverse events requiring study drug discontinuation among patients receiving active therapy.


Non pharmacological intervention :  

PERCUTANEOUS CORONARY INTERVENTION.

Percutaneous Coronary Intervention  is a non-surgical procedure that uses a catheter (a thin flexible tube) to place a small structure called a stent to open up blood vessels in the heart that have been narrowed by plaque buildup ( atherosclerosis).


3) What are the indications and contraindications for PCI?

 Ans:   INDICATIONS:

        Acute ST-elevation myocardial infarction (STEMI)

         Non–ST-elevation acute coronary syndrome (NSTE-ACS)

          Unstable angina.

         Stable angina.

         Anginal equivalent (eg, dyspnea, arrhythmia, or dizziness or syncope)

         High risk stress test findings.      

CONTRAINDICATIONS:

     Intolerance for oral antiplatelets long-term.

     Absence of cardiac surgery backup.

      Hypercoagulable state.

      High-grade chronic kidney disease.

      Chronic total occlusion of SVG.

      An artery with a diameter of <1.5 mm.

 

4) What happens if a PCI is performed in a patient who does not need it? What are the harms of overtreatment and why is research on overtesting and overtreatment important to current healthcare systems?

 Ans: Although PCI is generally a safe procedure , it might cause serious certain complications like 

A)Bleeding 

B) Blood vessel damage

C) Allergic reaction to the contrast dye used

D) Arrhythmias

E) Need for emergency coronary artery bypass grafting .

Because of all these complications it is better to avoid PCI in patients who do not require it.


OVER TESTING AND OVER TRAETMENT HAVE BECOME COMMMIN IN TODAY’S MEDICAL PRACTICE.

Research on overtesting and overtreatment is important as they are more harmful than useful.

Following are harms to patients:

. Performing screening tests in patients with who at low risk for the disease which is being screened.

For example:Breast Cancer Screenings Can Cause More Harm Than Good in Women Who Are at Low Risk. A harmless lump or bump could incorrectly come up as cancer during routine breast screenings. This means that some women undergo surgery, chemotherapy or radiation for cancer that was never there in the first place.

.Overuse of imaging techniques such as X- RAYS AND CT SCANS as a part of routine investigations. 

 Overuse of imaging can lead to a diagnosis of a condition that would have otherwise remained irrelevant -

 OVERDIAGNOSIS.

Also the adverse effects due to this are more when compared to the benefits.

.Overdiagnosis through overtesting can psychologically harm the patient.

Hospitalizations for those with chronic conditions who could be treated as outpatients[ can lead to economic burden and a feeling of isolation.


Harms to health care systems:

The use of expensive technologies and machineries are causing burden on health care systems.

 

E) Link to patient details:

 

https://bhavaniv.blogspot.com/2021/05/case-discussion-on-myocardial-infarction.html?m=1



 

 

Questions:

 

1) What is the evolution of the symptomatology in this patient in terms of an event timeline and where is the anatomical localization for the problem and what is the primary etiology of the patient's problem?

 Ans:VOLUTION OF SYMTOMATOLOGY

 diabetic since 8 years

hypertension since 8 years

took first dose of COVISHIELD  vaccine 5 days back before admn to hospital

chest pain in right side of chest

giddiness and profuse sweating on day of the admission

ANATOMICAL LOCATION OF PROBLEM: cardio vascular system


PRIMARY ETIOLOGY OF PATIENT PROBLEM: as she is diabetic since 8 years that might cause atherosclerosis due to accumulation of fatty and fibrinous material in the walls


2) What are mechanism of action, indication and efficacy over placebo of each of the pharmacological and non pharmacological interventions used for this patient?

 Ans:

 Pharmacological interventions:

  tab  ASPIRIN 325 mg 

MOA: inhibits platelet aggregation by interfering with thromboxane in platelets caused by COX 1 inhibition


  indications :

 to reduce the cardio vascular deaths in suspected case of MI

 efficacy: 

low dose aspirin each day for atlaest 10 years lower the risk of cvd by 10% and odds ratio from 0.85 to 0.90

tab ATORVASTATIN 80 mg

MOA :competitive inhibitor of enzyme HMG CO A reductase

indication:

to prevent CV events in patients who are at risk used as preventive agent 

efficacy:

 studies shown that it decrease LDL cholestrol concentration by61% and triglycerides by 46%

tab clopidegrel 300 mg 

  MOA : Inhibitor of platelet aggregation by binding one of the ADP receptors on platelets

indications: 

ACS

recent MI ,recent stroke ,peripheral arterial disease

3) Did the secondary PTCA do any good to the patient or was it unnecessary?

 Ans:   yes it is good to patient,  stent was placed and the patient is doing good

F) Link to patient details:

 

https://kattekolasathwik.blogspot.com/2021/05/a-case-of-cardiogenic-shock.h

 

1. How did the patient get  relieved from his shortness of breath after i.v fluids administration by rural medical practitioner?

 Ans: May be the rural medical practitioner gave a diuretic which decreased the fluid overload on lungs there by relieving sob.


2. What is the rationale of using torsemide in this patient?

 Ans: Torsemide is used to reduce extra fluid in the body as the heart is already in shock state , any extra fluid in the body worsens the condition of heart.

3. Was the rationale for administration of ceftriaxone? Was it prophylactic or for the treatment of UTI?

 Ans:

 

4) Gastroenterology (& Pulmonology) 10 Marks

 

A) Link to patient details:

 

https://63konakanchihyndavi.blogspot.com/2021/05/case-discussion-on-pancreatitis-with.html

 

QUESTIONS: 

 

1) What is the evolution of the symptomatology in this patient in terms of an event timeline and where is the anatomical localization for the problem and what is the primary etiology of the patient's problem?

 Ans: 


Evolution of symptomatology 

H5 years back-1st episode of pain abdomen and vomitings 

Stopped taking alcohol for 3 years

1 year back 5 to 6 episodes of pain abdomen and vomitings after starting to drink alcohol again 

20 days back increased consumption of toddy intake

Since 1 week pain abdomen and vomiting

Since 4 days fever constipation and burning micturition

Anatomical localisation: Pancreas and left lung


Alcohol and its metabolites produce changes in the acinar cells, which may promote premature intracellular digestive enzyme activation thereby predisposing the gland to autodigestive injury. Pancreatic stellate cells (PSCs) are activated directly by alcohol and its metabolites and also by cytokines and growth factors released during alcohol-induced pancreatic necroinflammation. Activated PSCs are the key cells responsible for producing the fibrosis of alcoholic chronic pancreatitis





2) What is the efficacy of drugs used along with other non pharmacological  treatment modalities and how would  you approach this patient as a treating physician?

 Ans: 1.ZOSTUM Inj 

Mechanism of action:antibacterial 

Indications: used to treat severe and serious bacterial infections such as respiratory tract infection, urinary tract infection, skin and soft tissue infection, joint and bone infection 

Efficacy https://www.researchgate.net/publication/303996525_A_Study_on_prescribing_and_cost_pattern_of_antimicrobial_agents_in_a_tertiary_care_teaching_hospital

  2.inj METROGYL 

Mechanism of action:anti bacterial and anti parasitic

Indications used to treat diarrhoea or dysentery due to parasitic infections such as amoebiasis. It is used to prevent sexually transmitted infections such as urogenital trichomoniasis or giardiasis. It is also used to treat infections of the gums, teeth and skin due to various infective microorganisms

3.ULTRACET 

Mechanism of action: centrally acting analgesic

Indications  moderate to severe pain

Approach to treat the patient

Antibiotics given to combact infection

TNP preferred because of the gastrointestinal symptoms of the patient.

Pleural effusion should be drained

 

B) Link to patient details:

 

https://nehae-logs.blogspot.com/2021/05/case-discussion-on-25-year-old-male.html

 

 

1) What is causing the patient's dyspnea? How is it related to pancreatitis?

 Ans: Pancreatitis can cause chemical changes in the body that can effect lung function causing respiratory symptoms. 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4087768/

2) Name possible reasons why the patient has developed a state of hyperglycemia.

 Ans:)Chronic inflammation of the pancreas can damage the beta cells producing insulin which can lead development of diabetic state

And also diabetes and pancreatitis have some risk factors in common like alcohol

3) What is the reason for his elevated LFTs? Is there a specific marker for Alcoholic Fatty Liver disease?

 Ans: )Fatty liver changes are seen in patients with pancreatitis and the patient being a alcoholic some fatty changes can already be present.

An ALT to AST ratio over 2 is highly suggestive of alcohol liver disease.

4) What is the line of treatment in this patient?

 Ans:

Line of treatment;

    i)manage hyperglycemia and monitor GRBS

   ii)ask the patient to stop alcohol consumption.

 

C) Link to patient details:

 

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

 

Possible Questions :-

 

1) what is the most probable diagnosis in this patient?

 Ans: Probable diagnosis is hollow viscus perforation and its effects like free fluid and hematoma formation.

2) What was the cause of her death?

 Ans:Cause of her death can be as a complication of surgery in the form of pneumonia(As symptom just before the death are cough and sob) as many people who undergo surgery already have weakened immune system and they are prone to get infections.

3) Does her NSAID abuse have  something to do with her condition? How? 

 Ans:Effect of nsaids abuse ; nsaids are known risk factor for peptic ulcer formation and a complication of ulcer in git is perforation.so nsaids abuse can have contributed to her disease outcome.


5) Nephrology (and Urology) 10 Marks 

 

A) Link to patient details:

 

https://kavyasamudrala.blogspot.com/2021/05/medicine-case-discussion-this-is-online.html

 

1. What could be the reason for his SOB ?

 Ans: His sob was is due to Acidosis which was caused by Diuretics

                              Turp

2. Why does he have intermittent episodes of  drowsiness ?

 Ans:-Hyponatremia was the cause for his drowsiness 


3. Why did he complaint of fleshy mass like passage in his urine?

 Ans: plenty of pus cells in his urine passage  appeared as

 fleshy mass like passage to him


4. What are the complications of TURP that he may have had?

 Ans:   Difficulty micturition

        Electrolyte imbalances

         Infection

B) Link to patient details:

 

 

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

 

 

Questions

 

1.Why is the child excessively hyperactive without much of social etiquettes ?

 Ans:The symptoms of the child point the diagnosis towards ADHD (attention deficit hyperactivity disorder)

2. Why doesn't the child have the excessive urge of urination at night time ?

 Ans: As the child do not have bedwetting nor waking up at night to pass urine it can be a case of receptor over activity effected by gravity(neurogenic overactivity bladder) or pollakiuria(idiopathic frequent urination)it can also be psychosomatic as his mother completely restricted him from using smartphone since 4 months before which he is addicted to ,so the child sleeps normally at night.

3. How would you want to manage the patient to relieve him of his symptoms?

 Ans: First look if any pathology is present in the genitourinary system, then try with the help of psychiatrist find whether it is adhd or not, if yes do cognitive behaviour therapy.


 

 





6) Infectious Disease (HI virus, Mycobacteria, Gastroenterology, Pulmonology)  10 Marks 

 

A) Link to patient details:

 

 

https://vyshnavikonakalla.blogspot.com/2021/05/a-40-year-old-lady-with-dysphagia-fever.html

 

 

Questions:

 

 1.Which clinical history and physical findings are characteristic of tracheo esophageal fistula?

 Ans: :clinical history and physical findings---

Cough since 2 months on taking food and liquids 

difficulty in swallowing since 2 month

H/O weight loss of 10 Kgs since 2 months, hoarseness of voice

Incapable of food intake

Oropharygeal regurgitation

2) What are the chances of this patient developing immune reconstitution inflammatory syndrome? Can we prevent it? 

 Ans: A retrospective analysis examining all forms of IRIS, 33/132 (25%) of patients exhibited one or more disease episodes after initiation of ART. Other cohort analyses examining all manifestations of IRIS estimate that 17–23% of patients initiating ART will develop the syndrome.

: REVENTION :

The most effective prevention of IRIS would involve initiation of ART before the development of advanced immunosuppression. IRIS is uncommon in individuals who initiate antiretroviral treatment with a CD4+ T-cell count greater than 100 cells/uL.

 


 


7) Infectious disease and Hepatology:

 

Link to patient details:

 

 

https://kavyasamudrala.blogspot.com/2021/05/liver-abscess.html

 

 

 

1. Do you think drinking locally made alcohol caused liver abscess in this patient due to predisposing factors

 present in it ? What could be the cause in this patient ?

 

 Ans:  yes, it could be due to intake of contaminated toddy


 

2. What is the etiopathogenesis  of liver abscess in a chronic alcoholic patient ? ( since 30 years - 1 bottle per day)

 Ans:-ccording to some studies, alcoholism mainly consuming locally prepared alcohol plays a major role as a predisposing factor for the formation of liver abscesses that is both amoebic as well as pyogenic liver abscess because of the adverse effects of alcohol over the Liver. 


3. Is liver abscess more common in right lobe ?

 Ans:-yes right lobe is involved due to its moreblood supply



4.What are the indications for ultrasound guided aspiration of liver abscess ?

 Ans:1. Large abscess more than 6cms

2. Left lobe abscess

3.Caudate lobe abscess

4. Abscess which is not responding to drugs

 

 

 

 

B) Link to patient details:

 

 

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

 

QUESTIONS:

 

 

1) Cause of liver abcess in this patient ?

 Ans:; the cause of liver abcess is :


* Amoebic liver abcess (ALA ) seen commonly in the tropics is predominantly confined to adult males, especially those who consume locally brewed alcohol, although intestinal amoebiasis occurs in all age groups and in both genders.


* It has been argued that socioeconomic factors and poor sanitary conditions are the primary culprits that casually link alcohol to ALA.


* However , there has emerged an abundance of data that implicates alcohol in a more causal role in facilitating the extraintestinal invasion of the infective protozoan and the subsequent development of ALA.


## Hence the consumption of locally made alcohol ( toddy ) is the most likely cause of Liver abcess in this patient.



 

2) How do you approach this patient ?

 Ans:  The patient is well managed by treating team ; even me will follow the same approach.

 

3) Why do we treat here ; both amoebic and pyogenic liver abcess? 

 Ans: * Considering the following factors:

    1) Age and gender of patient: 21 years ( young ) and male.

   2) Single abcess.

   3) Right lobe involvement.


## The abcess is most likely AMOEBIC LIVER ABSCESS … 

 

** But most of the patients with amoebic liver abcess have no bowel symptoms, examination of stool for ova and parasite and antigen testing is insensitive and insensitive and not recommended.

 

# And considering the risk factors associated with aspiration for pus culture:


1) Sometimes ; abcess is not accessible for aspiration if it is in posterior aspect or so.

2) Sometimes ; it has thin thinwall which may rupture if u aspirate.

3) Sometimes ; it is unliquefied.


## There how can u confirm whether it is pyogenic/ amoebic , so we treat them both empirically in clinical practice.


4) Is there a way to confirmthe definitive diagnosis in this patient?

 Ans: Yes in a high resource setting cause of liver abscess is usually determined using multiple diagnostic strategies , including blood cultures , entamoeba serology , liver abscess aspirate for culture and molecular and antigen testing.

8) Infectious disease (Mucormycosis, Ophthalmology, Otorhinolaryngology, Neurology) 10 Marks 

 

A) Link to patient details:

 

 

http://manikaraovinay.blogspot.com/2021/05/50male-came-in-altered-sensorium.html

 

Questions :

 


1) What is the evolution of the symptomatology in this patient in terms of an event timeline and where is the anatomical localization for the problem and what is the primary etiology of the patient's problem?

Ans:

    3 years ago- diagnosed with hypertension

2.     21 days ago- received vaccination at local PHC which was followed by fever associated with chills and rigors, high grade fever, no diurnal variation which was relieved on medication

3.     18 days ago- complained of similar events and went to the the local hospital, it was not subsided upon taking medication(antipyretics)

4.     11 days ago - c/o Generalized weakness and facial puffiness and periorbital oedema. Patient was in a drowsy state

5.     4 days ago-  

a.     patient presented to casualty in altered state with facial puffiness and periorbital oedema and weakness of right upper limb and lower limb

b.     towards the evening patient periorbital oedema progressed

c.      serous discharge from the left eye that was blood tinged

d.     was diagnosed with diabetes mellitus

6.     patient was referred to a government general hospital

7.     patient died 2 days ago

 

patient was diagnosed with diabetic ketoacidosis and was unaware that he was diabetic until then. This resulted in poorly controlled blood sugar levels. The patient was diagnosed with acute oro rhino orbital mucormycosis . rhino cerebral mucormycosis is the most common form of this fungus that occurs in people with uncontrolled diabetes ( https://www.cdc.gov/fungal/diseases/mucormycosis/definition.html ) the fungus enters the sinuses from the environment and then the brain.

The patient was also diagnosed with acute infarct in the left frontal and temporal lobe. Mucormycosis is associated with the occurrence of CVA ( https://journal.chestnet.org/article/S0012-3692(19)33482-8/fulltext#:~:text=There%20are%20few%20incidences%20reported,to%20better%20morbidity%2Fmortality%20outcomes. )

2) What is the efficacy of drugs used along with other non pharmacological  treatment modalities and how would  you approach this patient as a treating physician?

 Ans:

The proposed management of the patient was –

1.     inj. Liposomal amphotericin B according to creatinine clearance

2.     200mg Iitraconazole was given as it was the only available drug which was adjusted to his creatinine clearance

3.     Deoxycholate was the required drug which was unavailable

https://pubmed.ncbi.nlm.nih.gov/23729001/ this article talks about the efficacy and toxicity of different formulations of amphotericin B

along with the above mentioned treatment for the patient managing others symptoms is also done by-

       I.          Management of diabetic ketoacidosis –

(a)   Fluid replacement-  The fluids will replace those lost through excessive urination, as well as help dilute the excess sugar in blood.

(b)   Electrolyte replacement-The absence of insulin can lower the level of several electrolytes in blood. Patient will receive electrolytes through a vein to help keep the heart, muscles and nerve cells functioning normally.

                      (c)  Insulin therapy-  Insulin reverses the processes that cause diabetic ketoacidosis. In addition to fluids and electrolytes, patient will receive insulin therapy

3) What are the postulated reasons for a sudden apparent rise in the incidence of mucormycosis in India at this point of time? 

 Ans :

Mucormycosis is may be being triggered by the use of steroids, a life-saving treatment for severe and critically ill Covid-19 patients. Steroids reduce inflammation in the lungs for Covid-19 and appear to help stop some of the damage that can happen when the body's immune system goes into overdrive to fight off coronavirus. But they also reduce immunity and push up blood sugar levels in both diabetics and non-diabetic Covid-19 patients.

With the COVID-19 cases rising in India the rate of occurrence of mucormycosis in these patients is increasing


9) Infectious Disease (Covid 19)

As  these patients are currently taking up more than 50% of our time we decided to make a separate log link here:


for this question that contains details of many of our covid 19 patients documented over this month and we would like you to:

1) Sort out these detailed patient case report logs into a single web page as a master chart 

2) In the master chart classify the patient case report logs into mild, moderate severe and 

3) indicate for each patient, the day of covid when their severity changed from moderate to severe or vice versa recognized primarily through increasing or decreasing oxygen requirements 

4) Indicate the sequence of specific terminal events for those who died with severe covid (for example, altered sensorium, hypotension etc). 
 Ans:
covid cases master chart

S NO

PATIENT E LOG LINKS

AGE

GENDER

SEVERITY

CHANGE OF SEVERITY

CHANGE OF O2 SATURATION

COMPLIACATION S

OUTCOME

1

https://nikhilasampathkumar.blogspot.com/2021/05/covid-pneumonia-in-pre-existing-case-of.html

58

F

Moderate

On 11th day to resolution

93%

Viral pneumonia

Resolution

2

https://nehapradeep99.blogspot.com/2021/05/a-50-year-old-female-with-viral.html

50

F

Moderate

On 4/05/21 to severe form

95% to 97%

Viral pneumonia and de novo DM

Resolution

3

https://143vibhahegde.blogspot.com/2021/05/covid-in-26-yo-female.html

26

F

Severe

 

75% on 16L O2

Renal complications

Death

4

https://gsuhithagnaneswar.blogspot.com/2021/05/29-year-old-male-patient-with-viral.html?m=1

29

M

Mild

On 19/4/21 from mild to severe form

98% to 99%

Viral pneumonia

Resolution

5

https://anuragreddy72.blogspot.com/2021/05/case-discussion-on-hypokalemic-periodic.html

45

M

Severe

On 17/5/21 from moderate to severe

20%

Altered sensorium, hypokalaemia, azotemia

Resolution

6

https://vijaykumarkasturi.blogspot.com/2021/05/65-years-old-male-with-viral-pneumonia.html

65

M

Severe

 

78% to 80%

Liver and Renal complications

Death

7

https://drsaranyaroshni.blogspot.com/2021/05/a-67-year-old-lady-in-icu-with-covid.html

67

F

Moderate

On 17/5/21 from moderate to mild

85% to 95%

Viral pneumonia and ICU psychosis

Resolution

8

https://bhavaniv.blogspot.com/2021/05/35yrm-with-viral-pneumonia-secondary-to.html?m=1

35

M

Moderate

 

85% to 95%

Viral pneumonia

Resolution

9

https://vidya36.blogspot.com/2021/05/a-45-year-old-female-with-viral.html

45

F

Mild

 

85% to 95%

Viral pneumonia and de novo DM

Resolution

10

https://rishithareddy30.blogspot.com/2021/05/covid-case-report.html

50

F

Moderate

 

86-92% to 99%

Viral pneumonia and de novo DM

Resolution

11

https://93deepanandikonda.blogspot.com/2021/05/42-years-female-patient-with-viral.html

42

F

Moderate

On 15/5/21

82% to 95%

Viral pneumonia

Resolution

12

https://vignatha45.blogspot.com/2021/05/58-years-female-patient-with-viral.html

58

F

Moderate

 

88% at 16L of O2

Uncontrolled hyperglycaemia

Death

13

https://jahnavichatla.blogspot.com/2021/05/covid-case-discussion.html

55

M

Severe

On 20/5/21 to Moderate

85% to 95%

Viral pneumonia and ICU psychosis

Resolution

14

https://meghanaraomuddada.blogspot.com/2021/05/case-1-2021-42yr-old-male-with-fever.html

42

M

Moderate

 

86% to 90%

Viral pneumonia

Resolution

15

https://vaishnavimaguluri138.blogspot.com/2021/05/viral-pneumonia-secondary-to-covid-19.html

35

M

Mild

 

87% to 95%

Viral pneumonia

Resolution

16

https://prathyushamulukala666.blogspot.com/2021/05/a-62-year-old-male-patient-with-fever.html

62

M

Moderate

 

88% to 90%

Viral pneumonia

Resolution

17

https://meesumabbas82.blogspot.com/2021/05/a-38-yo-male-with-viral-pneumonia.html

38

M

Mild

 

92% to 99%

Viral pneumonia

Resolution

18

https://srilekha77.blogspot.com/2021/05/a-48-year-male-with-viral-pneumonia-due.html

48

M

Moderate

On 8/5/21 to severe

90%

Viral pneumonia

Resolution

19

https://sudhamshireddy.blogspot.com/2021/05/a-65-year-old-female-with-fever.html

65

F

Severe

On 16/5/21

93%

ARDS

Death

20

https://nehae-logs.blogspot.com/2021/05/case-discussion-on-viral-pneumonia.html

63

M

Severe

 

75% to 91%

Viral pneumonia

 




10) Medical Education: (10 marks) 

Experiential learning is a very important method of Medical education and while the E logs of the students in the questions above represent partly their and their patient's experiences, reflective logging  of one's own experiences is a vital tool toward competency development in medical education and research. A sample answer to this last assignment around sharing your experience log of the month can be seen in the link below but while this is by a student onsite in hospital  and not locked down at home we would be very interested to learn about your telemedical learning experiences from our hospital as well as community  patients over the last month even while locked down at home: 
 Ans : 6th may: previous elogs of our senior batch were shared with us. they gave us an idea of how to do elogs
 
8th may : covid patient updates were shared along with the CT scan and x ray finding and other investigations which were done. the treatment plan was also discussed .

10th may : a case of liver abscess was discussed 
21/M student occasional toddy drinker Came with 
H/o pain in the epigastrium & right hypochondrium , loss of appetite & fever from 20 days - diagnosed as liver abscess & got treated outside.
In  spite of he was having intermittent pain & fever for which he came to our hospital.
O/E:
Pt C/C/C,PR: 82 bpm, BP: 110/70 mmhg
CVS: S1 S2 + , no murmurs,RS: BAE+ , NVBS
P/A: Soft , NT ,CNS: NFND
Dx:
Liver abscess (segment VII of right lobe with 50 to 60% liquefaction)
And our doubts regarding treatment protocols of Covid were clarified, this discussion helped to clear a lot of doubts regarding Covid treatment.

May 11: the following case was discussed in a great detail 
67yrs female
Diagnosis-Viral pnemonia secondary to COVID-19, HTN, HYPOTHYROIDISM, CENTRAL OBESITY, CVA
She was having hypersomnolence in the day time during yesterday's morning rounds. 
Later her son told me she had phoned them at 3:00 AM yesterday complaining that there was a man here who was threatening to take her away by morning. We checked the CCTV footage during that time yesterday and didn't find anyone near her bed except she did appear to wake up sometime around that time and was on the phone. 
With this case I have understood the neuropsychiatric aspects of COVID .

May 12:updates of Covid cases were given 

May 13: an interesting case of 8 year old boy with frequent micturition was discussed

May 14 : differential diagnosis for a 78 year old Male with pericardial effusion was discussed 

May 15; a case of ICU psychosis with Covid infection has been discussed 

May 16: Covid cases updates where given.

May 17: 2 cardiology cases where discussed along with their elogs. Discussion about percutaneous intervention was done.

May 18: case of tracheo oesophageal fistula with the endoscopic video was shared
In the 2-4 session a session with the attenders of Covid patients with their case discussion was done

May 19: Acute cerebral vascular accident case was shared along with the MRI image findings 

May 20: elogs of Covid patients were shared by many students 
Going through these elogs  which were made by many students helped me to get know about all cases in the hospital ,through elogs we can cover lot of cases.

May 21: a case with differential of Wernicke and withdrawal was discussed and the key points on how to diagnose were put on ex: thiamine administration improves the patient condition in Wernicke’s encephalopathy where as the condition remains same in withdrawal.

May 22: questions regarding the cases in elogs were put up finding answers to these questions helped me to go through many research papers And trials which was very 

May 23: some other elogs with questions were shared.
Afternoon session for case discussion was done.

May 24: discussion about stroke score was done
  I’ve leaned a new term today
PPCRA - Peripapillary chorioretinal atrophy  
This can be seen in myopics and in some cases of glaucoma.

May 25: discussion about granulation tissue formation and its association with healing of an ulcer was done.

May 26: a case of pancreatitis with pleural effusion and  case of pemphigus Bulgaria with clinical pictures was posted.

May 27: clinical picture of Ascites in a female was shared
A detailed discussion about usage of antivirals in Covid was done. Efficacy of antivirals with study trials were shared.

May 28: a case of steroid induced Cushing syndrome was shared.
  In this current situations which is difficult  not only for us students but our professors who provide us knowledge I learnt so many things including both physical and mental balance
I  WOULD THANK RAKESH BISWAS SIR   ...... 

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