"MY EXPERIENCES WITH GENERAL CELLULAR AND NEURAL CELLULAR PATHOLOGY IN A CASE BASED BLENDED LEARNING ECOSYSTEM'S CBBLE "
"MY EXPERIENCES WITH GENERAL CELLULAR AND NEURAL CELLULAR PATHOLOGY IN A CASE BASED BLENDED LEARNING ECOSYSTEM'S CBBLE "
I am R Akhil Chowdary, a final year medical student at Kamineni Institute of Medical Sciences. I am very passionate about medicine and in learning how we can make a difference in patient lives. Towards which I am continuing to work and contribute by educating people on various such cases under the guidance of my professors,senior residents and discussing along with peers. I believe my interest in medicine make me successful in pursuing my career.Each and every patient i encounter and examine make me to learn about new outcomes and new treatment processes.Here are some of the cases which had made an impact on my life in terms of learning medicine .
CBBLE PAJR PARTICIPATORY LEARNING ACTION RESEARCH DISCLAIMER
NOTE: THIS IS AN ONLINE E LOGBOOK 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 A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS INTENDING TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT.
MY FIRST CASE AND EXPERIENCE OF A 78 YRS OLD MALE WITH SOB AND PEDAL EDEMA
My first interaction with a patient had occured during my 3rd semester in general medicine department who was a patient of 78 yrs male looking weak lying on the bed and after introducing myself and asking about his problems he was complaining about shortness of breath on exertion since last 3 months and also was complaining about generalized weakness since last 20 days and his legs were also swollen upto knees which is pedal edema which was of pitting type
On taking a detailed history i got to know that he had orthopnea and Pnd and also had a history of intermittent fever attacks which were all troubling him. As a 3rd sem student i had limited knowledge and had doubts related to all the history given by him and their inter relations so i had went through some of the online sources which had given me a knowledge regarding them
On going detail into past history he was diagnosed with dengue a month before and was a known diabetic since 10 years ad was on Tab Zoryl m2 and also he had a k/c/o seizure disorder and was on Tab Carbamazepine 200mg.
Coming to his personal history he had adequate sleep but his appetite was decreased and his bowel movements were irregular and he was an occasional alcoholic and was a non smoker.
On Physical examination of the patient i had seen that he had severe pallor with pedal edema bilaterally upto knees .
Going through the investigation reports which he had undergone, on Seeing his hemogram reports is Hb ,Mcv,Mch all values were low which were pointing me towards Anemia .He was diagnosed as a patient of Heart failure and anemia with Dm type 2 and seizure disorder , he was given medication of lasix 20mg ,tab zory m2,tab ecosprin av(70/20),tab carbamazepine 200mg and was advised to bp monitoring and glucose monitoring regularly .
CASE LINK :
https://rakhilchowdaryrollno136.blogspot.com/2021/12/78-yr-old-male-with-sobpedal-edema.html?m=1
My Learning :
By this case I had learned about heart failure (in which heart is unable to pump the required amount of blood which may cause the patients to experience Dyspnea( may be due to pulmonary congestion ) , pedal edema( due to rise in the capillary hydrostatic pressure ) and relation of heart failure with anemia (heart failure may cause decrease in the erythropoietin levels and iron levels which are required for synthesis of Rbc and anemia inversely may cause load on the heart physiologically for more production of rbc which all may have caused the patient to experience the above symptoms )
38 YR OLD MALE WITH PAIN ABDOMEN AND FEVER
This was a 38 yr old male patient case taken by me during my postings in 9th sem in which patient was feeling very uncomfortable to interact with people due to his weakness but after my clear explaination about need for his detailing about his situation which leads to his better treatment outcome he than co operated with me and started detailing about his situation .
The Patient had pain abdomen in right hypochondrium right lumbar and umbilical region which was pricking type which used to aggravate on inspiration . He also had fever assoc with chills and rigor which increased during nights and temporarily relieved on medication .he also had cough since 3 days, night sweats,weight loss seen.He actually went to local hospital about the fever and abdominal pain but was relieved only temporarily and re appeared after a day so he came for our hospital for treatment
He was later examined and investigations were done .For the details regarding examination and investigations visit the link below
Then on evaluation of chest x ray there was loss of costophrenic angle on left side which indicated pleural effusion which might be the reason behind his unexplained pain abdomen and was on medication with antipyretics and antibiotics for the relief of fever and they were not relieving his fever and based on above history of night sweats unresolving fever there was a suspicion of TB so then he advised for the ADA levels in pleural fluid which was checked through obtaining pleural fluid through pleural tap and unfortunately his ada levels was 75.6 U/L which confirmed his suspicion of TB.
MY LEARNING : This case had made to learn about the beauty of x ray in detecting pleural effusion as seen through the loss of costophrenic angle due to buildup of fluid which pushes the diaphragm out of angle which caused the blunting of the angle and about the TB which was causing him serious discomfort through his fever night sweats and cough and was detected through ADA levels in pleural fluid which was obtained due to pleural tap (which was the first time I had visualised the procedure which made more interested and curious towards learning medicine )and then he was explained about the disease and advised and recommended with ATT regimen.
CASE LINK:
https://rakhilchowdaryrollno136.blogspot.com/2023/04/32-yr-old-male-with-pain-abdomen.html
45 YR OLD MALE WITH PAIN ABDOMEN AND CONSTIPATION
This was patient with complaints of pain abdomen and constipation along with vomitings after eating food since 3 days on asking about his past history he had similar complaint of pain abdomen 1 yr back and was diagnosed as acute pancreatitis and was treated . on going to his personal history he had habit of Consumer 1 quarter of alcohol (whiskey) everyday
He he was then examined and on systemic examination he had tenderness in epigastric region and also his bowel sounds were reduced.on investigation findings his sgot sgpt levels and his Serum amylase- 841
Serum lipase- 218 levels were highly raised and On further evaluation he was diagnosed as case of Acute Pancreatitis
For further details related to case refer the link below
CASE LINK: https://rakhilchowdaryrollno136.blogspot.com/2023/04/45-yr-old-male-with-pain-abdomen.html
MY LEARNING: This case of Acute pancreatitis which might be related to his habit of chronic alcohol intake which might be the reason fir the inflammation of pancreas, and rise in levels of the enzymes which even was diagnosed a year earlier but due to continuous intake despite the advice made him showing the same complaints with increased severity again .For the more knowledge regarding pancreatitis i had referred from the online source referred below
https://www.ncbi.nlm.nih.gov/books/NBK482468/
60 YR OLD MALE WITH CKD
I Interacted with this patient during one of my postings where the person was seen with B/L pedal edema extended upto knees and Decreased urine output since 2 months with increase in frequency and has h/o nocturia , he also developed Sob 10 days back progressive started with grade 1 and progressed to grade 3 aggravated by walking and relieved on taking prolonged rest . he was a K/c/o Diabetes since 6 yrs(tab.glimi),K/c/o Htn since 3 yrs (tab amlokind) also had H/o fistulectomy 5 yrs back. He was further examined and investigated .for further details see the link below .He was diagnosed as a case of Chronic kidney disease
MY LEARNING : On investigating his urea levels were around 190mg/dl and creatinine levels were 8.5mg/dl with hyponatremia and hyperphosphatemia and there was a decreased in rbc count which were all clear defining indicators of Renal failure. And he was undergone 4 episodes of dialysis( got to know about the procedure of dialysis which helps in removing the excess waste products which the kidney failed to excrete because of failure ) since last 10 days
CASE LINK:
https://rakhilchowdaryrollno136.blogspot.com/2023/04/60-yr-old-male-with-ckd.html
48 YEAR OLD MALE WITH ABDOMEN DISTENSION AND SOB
Patient was a 48 year old male auto driver was a chronic alcoholic was seen with distended abdomen lying on the bed and as had severe discomfort to speak history it was taken by me from his wife who was beside his bed worrying. His wife said that he was also complaining about Breathlessness since 20 days and also he had Swelling of bilateral lower limbs(pedal edema upto knees pitting type) since 20 days with decreased urine output since 3 days on taking the detailed history he said that he also has a complaint of Shortness of breath since 10 days which was of progressive nature where initially he used to walk to his home without any problem after parking his auto at a distance from home.Now he has to take rest after walking some distance
On going to his past history he had generalized weakness, abdominal distension 2yrs back where he went to a local hospital and was diagnosed with Chronic liver disease and was rehabilitated and was advised of quitting alcohol and he was a K/C/O HTN since 10 years (using t.amlong 5 mg and atenolol 50 mg )
On asking about his Personal history he had mixed with appetite which was decreased and had decreased urine output and was chronic alcoholic since 2007 used to drink 250 to 300 ml alcohol everdayat night for the relief of the work load on him everyday.
He was further examined and investigations were done and was diagnosed as a case of Acute decompensation of chronic liver disease .For details of examination and investigation reports please refer the link below
MY LEARNING: This case has made me to learn about the effect of chronic consumption of alcohol which caused the liver damage which might have progressed initially from fatty liver and then to stage of inflammation (Hepatitis) which even might be resolved on taking medication and quitting alcohol which he had not done which had lead him to then decompensated stage of liver failure.And also learned more details about through following article .
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5513682/
CASE LINK :
https://rakhilchowdaryrollno136.blogspot.com/2023/04/48-yr-male-with-abdominal-distension.html
37 YEAR OLD MALE WITH LOW BACKACHE SINCE 10 MONTHS
This is a patient whom I had got chance to interact through phone call (Telephonic case taking) during the summer vacation. It was a great different experience of case taking and interacting with patients through this way and was a great opportunity of learning this way.
The patient was bengali patient but somehow managed to speak hindi which made my interaction with him easier.
He was a 37 yr old male patient resident of Coochbehar of westbengal started working as employee in private company, since 10 months developed low back ache which aggravates on sitting for longer duration and also associated with tingling sensation so he unable to sit for longer duration, He also said that he stopped lifting heavy weights because of back pain. He said that he had used antacids ? to relieve the pain from nearby pharmacy which was of no use , so he consulted a doctor in a local hospital in aug 2022 where he was investigated (mri and x ray)and was diagnosed as lumbar spondylosis and was given 6 injections Rejunuron on alt days followed by 4 injections of deca durabolin 50mg for every 3 weeks but there was no relief for the patient and was also diagnosed with hypertension and using tab .cilnidipine 10 mg since then .
He also said that he started having pain and tingling sensation in left foot since 4 months so he again consulted the doctor was given medication ( tab.nervite plus for 3 weeks ) and advised for surgery if the pain has not resolved further.
On going detail about his Past history he was a k/c/o Hypertension since 9 months on medication (tab.clinidipine 10 mg).k/c/o Lumbar spondylosis since 9 months.
Asking more about him made Patient share his personal details that he completed his education until 7th standard, he got married in 2011 have two kids ,1st child is female 11 yrs old and 2nd child boy 11 months. He is an employee in private company since 2008 . He regularly starts for work at 10 am and mostly travel on bike for the work related to company until 2pm and then he takes his lunch and sits in work place from 3 pm to 10 pm . Later he goes home have dinner and sleep by 12 am. He initially stopped riding bike because of backache and the stopped working since feb 2023 because of severe back pain.He had mixed diet with normal appetite and had Bowel and bladder movements regular and Had a habit of taking alcohol occasionally but since 2015 but stopped consuming completely since 1 and half year.
He was later examined and was investigated .(For Examination and investigation reports please refer the second blog link below
He was Diagnosed as a case of degenerative disc pathology (Lumbar Spondylosis)
CASE LINKS:
https://rakhilchowdaryrollno136.blogspot.com/2023/05/is-online-e-log-book-to-discuss-our.html?m=1
CASE DISCUSSION:
[10:02 pm, 15/05/2023] Rakesh Biswas: What are the questions identified?
[10:11 pm, 15/05/2023] Kshitij Sharma: Sir
Can his Hypertension by treated by non-pharmacologic method?
His lifestyle seems like a cause for his Hypertension!
[10:18 pm, 15/05/2023] Kshitij Sharma: Postural syndrome! @Manogna how long does he drives for (Distance ) and (duration) !
Considering the roads , the aforementioned factors can play significant role
[10:20 pm, 15/05/2023] +91 94914 18555: How would postural syndrome cause Hypertension in this patient?
[10:26 pm, 15/05/2023] Kshitij Sharma: Not the postural syndrome!
[10:27 pm, 15/05/2023] Kshitij Sharma: Hypertension might be a result of his lifestyle
[10:27 pm, 15/05/2023] Shivang: It can causes lumbar spondylosis
[10:28 pm, 15/05/2023] Shivang: Long-term, repetitive strain on your low back, whether occupational or recreational can causes lumbar spondylosis
[10:36 pm, 15/05/2023] Kshitij Sharma: https://pubmed.ncbi.nlm.nih.gov/9894438/
[10:36 pm, 15/05/2023] Kshitij Sharma: Stress can cause hypertension through repeated blood pressure elevations as well as by stimulation of the nervous system to produce large amounts of vasoconstricting hormones that increase blood pressure. Factors affecting blood pressure through stress include white coat hypertension, job strain, race, social environment, and emotional distress. Furthermore, when one risk factor is coupled with other stress producing factors, the effect on blood pressure is multiplied
[10:37 pm, 15/05/2023] Manogna: Q. In this case, the patient apparently claimed that the pain was not reduced even after going to physiotherapy or any other medications,
So how will we proceed sir?
[10:40 pm, 15/05/2023] Kshitij Sharma: Do we have his x-ray and mri from aug 2022?
[11:01 pm, 15/05/2023] Kshitij Sharma: Well! Let's find out the JOA SCORE for this pt. !?
[11:14 pm, 15/05/2023] +91 90008 00878: JOA SCORE = 1+2+3+2+1+2+1+0 = 12
[11:30 pm, 15/05/2023] +91 94914 18555: Operative treatment provides excellent results for patients with severe clinical presentation (JOA score ≤7), while individuals with mild to moderate spinal stenosis (JOA score >7) should receive conservative treatment.
[11:30 pm, 15/05/2023] +91 94914 18555: https://jorthoptraumatol.springeropen.com/articles/10.1007/s10195-005-0099-0
[11:30 pm, 15/05/2023] +91 94914 18555: That’s more than 7 so we should technically continue conservative treatment. But what can we do now that the patient is not responding to physiotherapy or medications?
[11:33 pm, 15/05/2023] Kshitij Sharma: Well! For that we have to find out the number of physiotherapy session the pt had...! Was he adherent to its schedule?
[11:34 pm, 15/05/2023] +91 90008 00878: Yes
[11:34 pm, 15/05/2023] +91 90008 00878: Normally it takes around 5-6 sessions to know whether the individual is responding or not
[11:35 pm, 15/05/2023] Kshitij Sharma: Atleast! Right?
[11:35 pm, 15/05/2023] +91 90008 00878: Yes
[11:36 pm, 15/05/2023] Kshitij Sharma: Asking the pt attender for that!
[5:40 am, 16/05/2023] Akhil Chowdary: He used to drive for around 3 to 4 hrs in a day with small breaks in between
[5:59 am, 16/05/2023] Akhil Chowdary: https://www.academia.edu/57976541/The_role_of_JOA_score_as_an_indication_for_surgical_or_conservative_treatment_of_symptomatic_degenerative_lumbar_spinal_stenosis
[8:29 am, 16/05/2023] Kshitij Sharma: He had 3 sessions of physiotherapy!
[9:38 am, 16/05/2023] Rakesh Biswas: What is the evidence for his hypertension?
Hourly BP charts?
[9:39 am, 16/05/2023] Rakesh Biswas: No statements to be made without sharing epidemiologic evidence
[9:39 am, 16/05/2023] Rakesh Biswas: Show the data
[9:40 am, 16/05/2023] Rakesh Biswas: We need to know more about the patient's sequence of events
[9:41 am, 16/05/2023] Akhil Chowdary: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2697338/
We are happy to see good research content in blogs
We need to develop our critical appraisal skills by looking for scientific data in whatever content is shared and learn to distinguish it from opinion
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