Fortnightly Feb 2020 INTERNAL ASSESSMENT EXAM FOR 1st and 2nd YEAR PG STUDENTS

 
DEPARTMENT OF GENERAL MEDICINE
INTERNAL ASSESSMENT EXAM FOR 1st and 2nd YEAR PG STUDENTS

Answer all questions                                                                                    Max Marks: 60

Time: 2pm to 4pm                                                                                       Date: 01.02.2020

There are in total ‘3’ questions. The 3 long questions are 20 marks each
with two parts of 10 marks, one specifically related to the case and the other more general as per tradition. The paper is designed to be answered by you in a blended offline and online format. Most of the real patient data presented here is due to our hardworking interns who have obtained signed informed consent from patients and then captured deidentified history and images. It has been shared nearly unchanged with minimal editing. 

Q1. A 50 year old man with progressive abdominal pain with vomiting since last 3 months and tenderness in the paraumbilical  region with no history suggestive of sepsis. On CT abdomen, patient was found to have a large cystic lesion in right hypochondrium possibly arising as a sequelae of pancreatic inflammation. Patient was admitted and put on injection taxim and injection tramadol for last 7 days.

a) Please check out the CT images of the abdomen (also check radspa and discuss with the Radiology PGs for the entire set of images) 

 and write the answers to the following: 

Where is the cyst anatomically located in relation to the pancreas? Is it in the greater sac or lesser sac or both? If in greater sac is it communicating with the pancreatic duct? Why is it not causing pancreatic ascites? What would be the disadvantages of an external drainage in such a situation? If planning internal drainage given the CT findings what would be the disadvantages of a cystogastrostomy vs cystojejunostomy? (3 marks) 

b) Is there a role of antibiotics in Pseudocyst without any evidence of sepsis? Please substantiate with evidence from review of literature (3 marks) 

c) What is the role of aspiration in management of an infected Pseudocyst? 

Please substantiate with evidence from review of literature (2 marks) 

d) What is the role of prophylactic antibiotics in intestinal obstruction? 

Please substantiate with evidence from review of literature (2 marks) 

Short note: Peritoneal relations with pancreas. (3 marks) 

Pancreatic pseudocyst (3 marks) 

ERCP and pancreatic duct (2 marks) 

Role of pancreatic necrosectomy (2 marks) 

Q2. A 55yr old male patient with diabetes since 7 yrs presented with c/o vomitings since 1 day(20 episodes non projectile and bilious) with right sided weakness and headache since 1 day .3 yrs back he had right sided weakness ,squint and weak memory for which he was admitted in a pvt hospital and diagnosed as acute cva for which he used allopathic medication for 2 months and ayurvedic medication for 3 yrs .he was asymptomatic for those 3 yrs but 1 week ago on 27/01/2020 he had 20 episodes of vomitings,non projectile and bilious, and a grbs of 300+ (tested at home with a glucometer )and developed slurred speech for which he was immediately taken to an rmp and given iv fluids overnight and  referred to our hospital in the morning.patient consumes alcohol occassionally and consumes chewable tobbacco since 30yrs. (History taken by intern)

1. Please examine the clinical images of his neurological findings during this admission and answer the following questions:

Higher mental functions: MMSE15

Cranial nerve examination: Inability to adduct the left eyeball with visible nystagmus in the right eye ball. Bilateral partial abduction of eyeballs. Absent sensations over left half of face.

Very prominent slurring of speech with marked scanning of each syllable and inability to pronounce jointed words (yuktaksharas).

Bilateral motor weakness of upper and lower limbs with lower limbs grade 3 minus and upper limb 4 minus. The right sided power is lesser than the left side.

What is the cranial nerve finding depicted above suggestive of in terms of anatomical localization?

If the etiology is vascular then which vessels are likely involved?

What could be the localization for his dementia? What information will help you to localize it further? (3)

2. Please go through the cranial MR images of the patient and comment on which cerebral territories are involved. (3)
3. What is the role of MR angio in further diagnosis? Will you advice it for this patient? (2)
4. What is the role of cerebral vessel stenting in this patient? Please review the literature on its evidence and share it in the PICO format.(2)

Short notes:

1. Weber’s syndrome (Neurology) (2)
2. Cerebrovascular disease etiologies (2)
3. Aspirin and stains in CVD prevention: evidence in PICO format (3)
4. Multiple infarct dementia (3)

Q3. 40 yrs female had h/o productive cough & cold for 10 days, three days after she went to a temple in chervugattu. In 3 days,she developed fever associated with headache and body pains.then she was admitted in govt. Hsptl, Nalgonda and stayed there for 5 days.after 3 days of hsptl stay in govt.hsptl,she had feeling of nausea and later vomitings. Then she went to a private hospital in Nalgonda and from there she was referred to our hospital. (History by intern) 

Her hospital fever chart showed high grade spikes (figure below)

On examination she has severe tachypnoea and crepitations over chest (right more than left) and her Spo2 reveals severe hypoxemia on room air with persistent hypoxia even on 100% oxygen. 

Chest X-ray reveals progression from non specific hilar infiltrates to batwing appearance and her WBC counts show a trend of 7000-11000. 

The next day’s chest X ray (image link) reveals bilateral moderate pleural effusion with loss of the previous alveolar opacities

What is your morphological and etiological differential diagnosis for this patient? (2)

How would you proceed to manage this patient if you suspect that there could be an infectious etiology? (6)

How would you prevent contagion? (2)

Short notes: (2x5)

1. SARs, MERs and Wuhan Corona virus 
2. ARDS infectious etiologies
3. Anatomical relations between alveoli and pleura
4. Disaster responsiveness 
5. Malaria ARDS: incidence, epidemiology and management

What is a Morbidity meeting?

MORTALITY / MORBIDITY MEETING NOTICE 

The morbidity meeting scheduled for 4th xxxuary, 2xxx (xxxday, 2.00 pm to 4.00pm)

Venue:  Auditorium

The first case presenting with a morbidity of 3 months and admitted with us for 7 days shared below is for illustrative purposes only and will not be presented. It has been shared to debate the current definition of morbidity meeting, which can in essence originate from any ‘patient with morbidity/illness,’ meeting his/her first caregiver and discussing his/her problems to move towards a sustainable solution (let’s call it m1). This would be followed by many more such meetings m1,m2,..Mn between various stakeholders in the patient’s care and one such may get presented in a mini auditorium such as ours but it doesn’t signify the end of morbidity meetings for the patient which is likely to continue till s/he finds a sustainable cure. Clinical audit of such care delivery pathways in patients (individual or collective) involves collecting patient data and analyzing it qualitatively by asking questions as a first step, finding out the answers from past experiential as well as empirical literature and finally sharing it in ‘morbidity meetings’ such as ours so that a collective opinion is shared to effect the patient’s subsequent care.

1. A 50 year old man with progressive abdominal pain with vomiting since last 3 months and tenderness in the paraumbilical  region with no history suggestive of sepsis. On CT abdomen, patient was found to have a large cystic lesion in right hypochondrium possibly arising as a sequelae of pancreatic inflammation. Patient was admitted and put on injection taxim and injection tramadol for last 7 days.

The following clinic audit queries need to be answered after the concerned PGs get in touch with the radiologist as well as review the literature.

Where is the cyst anatomically located in relation to the pancreas? Is it in the greater sac or lesser sac or both? If in greater sac is it communicating with the pancreatic duct? Why is it not causing pancreatic ascites? What would be the disadvantages of an external drainage in such a situation? If planning internal drainage given the CT findings what would be the disadvantages of a cystogastrostomy vs cystojejunostomy?

What is the role of antibiotics in Pseudocyst without any evidence of sepsis?

What is the role of aspiration in management of an infected Pseudocyst?

What is the role of prophylactic antibiotics in intestinal obstruction    

2. A 3 months old female child presented with complaints of cough and cold since 2 days, vomitings and rapid breathing since 2 days. Has issues of diagnostic and therapeutic uncertainties since xxth xxxuary 2xxx.  

3.A 55 years old man known case of congestive cardiac failure with reduced ejection fraction (21%) . 

Note: The presenting residents are requested to share further patient details with the current coordinating M & M team to facilitate the discussion for their presentations adequately.                

              COORDINATOR

                                              MORTALITY / MORBIDITY 

Whatsapp physician's disclaimer

Disclaimer by the telephysician in whatsapp after providing any kind of long distance information support (feel free to plagiarise if you engage in long distance patient information support aka Telemedicine in the stone age):

"Always be in touch with your local physician and inform him her about any decision that you take and essentially keep him her in the loop (even if it's in whatsapp) as the local physician can respond immediately physically in case of any sudden physical unpredictable issues).

Meanwhile I am happy to continue to support informationally from my long distance perch. 👍

PS: No issues with trespassing on this intellectual property but in keeping with "creative commons" laws please acknowledge this  whatsapp message in your quotes.

Patient centered questions for assessment of "Clinical problem solving and Medical decision making skills using EBM tools"

Introduction (to the question paper):

Dear student of Medicine (aka healthcare),

This is actually a formal question paper to be answered online using all available resources at your online disposal over a period of two days. Please submit your answers online by Monday or the nearest working day as we shall be using your inputs to not only assess you but also to help these patients asap as we believe your inputs reflecting your learning outcomes can be judiciously used to improve the healthcare outcomes of these "real" patients in the question paper. Our project is also trying to join the dots between learning outcomes and patient healthcare outcomes.

While this is a formal question paper and many of you answering this paper are working toward a formal licentiate degree in medicine and your inputs will count towards analyzing your cognitive skills in "clinical problem solving" this question paper will also be answered by a massive online audience who may not be as privileged as you to hold a licence to practice medicine and yet we believe their pluralistic inputs will go a long way to not only improve our patient outcomes but they will also improve our learning outcomes as we shall be filtering that pluralistic information to drive our patient outcomes in a transparent process in real time. 

Please answer all questions including the MCQs linked separately below each question description. Please feel to ask and add more questions around each one of these "patient centered questions" as YOUR clarifications and patient centered queries will help us develop further insights and we shall also assess your ability to ask questions (either Socratic or in a PICO format toward critical appraisal). Please feel free to google any  of the terminologies that you don't understand here. For those of you who have seen these current patients please share more information details about them that can enrich our systems thinking about their problem. 

You can either deposit your answer in the comment box or and email to kimsjbcr@gmail.com (the formal  email address for our journal that can be accessed here https://jbcr.net.in/) and or whatsapp to 9121046928 (this number cannot be called but just messaged with your name and you will receive an acknowledgement). 

We hope you will get used to this new format of assessing you once the shock value and novelty wears off. Just remember every information input that you provide to us around these questions will go a long way to help our patient teachers (more about them here 

https://userdrivenhealthcare.blogspot.com/2020/01/patient-as-teacher-video-part-1.html?m=1)

1) A 35 yr old man complains of shortness of breath since 2 weeks and pedal edema since 2 weeks

patient was apparently asymptomatic 1 month back then he developed fever , associated with chills ,which is high grade for which he took treatment at local rmp where he was given antimalarial drugs and treated symptomatically after which patient felt better. currently from 2 weeks he is complaining of b/l pedal edema, extending upto knees, pitting type, progressing in nature

shortness of breath from 2 weeks, initially NYHA grade III ,after treatment now grade II

h/o paroxysmal nocturnal dyspnea and generalised weakness from 2 weeks

no h/o fever,vomitings, abdominal distension, diarrhea, cough,cold

On examination, general examination reveals reduced muscle mass in limbs, large trunkal obesity, raised jvp and large bipedal edema. Cardiovascular system examination reveals an apex at the seventh intercostal space near the anterior axillary line on palpation and auscultation reveals a doubtful S4.

Available investigations

14/1/2020

HEMOGRAM: HB-15.2 , TLC-9600   , PLT-   2.39

LFT: TB- 2.03, DB- 0.84 , SGOT- 38, SGPT- 81, ALP- 347, TP- 7.1,ALBUMIN- 3.3, A/G RATIO - 0.87

RFT: UREA- 24 , CREATININE-0.8, URIC ACID-6.0 , CALCIUM- 10.1 PHOSPHORUS-4.2 SODIUM- 141, POTASSIUM- 4.3, CHLORIDE- 102

FBS-125   , PLBS -205, HBA1C-6.8

FLP: TOTAL CHOLESTEROL- 150

TRIGLYCERIDES- 87, HDL-33 ,LDL-  72 ,

VLDL- 17.4

HIV- non reactive  ,HBSAG - non reactive ,

HCV - non reactive

T3-0.84    ,T4-10.06    ,TSH -4.73       

USG ABDOMEN - Right moderate pleural effusion,Grade I fatty liver, mild ascitis .

2d echo- EF-27%, IVC dilated(2.3 cms) not collapsing, mild TR+, severe MR +, trivial AR +, Dilated all Chambers, Global hypokinesia, severe LV dysfunction, mild PAHT, no MS/AS , no PE/LV clot

Questions:

1)What could be the differentials postulated as possible etiologies and pathophysiologies for his clinical presentation? 

2) What are the diagnostic sensitivity and specificities of various modalities including clinical testing and other investigations for establishing a single diagnostic hypothesis for this patient with a fair degree of certainty? Please discuss and quote from available studies that you can come across to find the above and mention your search strategy for each study. 

3) What are the various therapeutic options/interventions for this patient? Please discuss the efficacy of each option/intervention quoting in a PICO format from studies that you can find around the efficacy of each intervention. Please share your search strategy for each of the possible interventions.

(For an illustrative example on search and appraisal read this article here https://ebm.bmj.com/content/7/3/68)

Please find the MCQs for the same patient prepared by our elective student here https://bmjcaselogvivek.blogspot.com/2020/01/patient-centered-questions-mcqs-for.html?m=1

2) A 62 year old man with diabetes since last twenty years and hypertension since ten years complains of shortness of breath and pedal edema since three years. He also complains of intermittent claudication pain of both lower limbs after walking for around 250 meters since last three years which subsides even with standing for a few minutes. He also complains of episodes of giddiness after walking and has been noted to have regular day time somnolence along episodes of nocturnal awakenings due to shortness of breath punctuated by snoring. He also complained of sudden diminished vision of one eye three months back.  

On examination he has large trunkal obesity and bilateral pedal edema along with hyperpigmentation of the skin and "peau de orange." His fundoscopy revealed a recovering vitreous hemorrhage with proliferative diabetic retinopathy. 

On investigations, his pulmonary function test and 2D Echo and an adenosine driven thallium perfusion scan turn out to be normal. His Hb is 8g % with microcytic hypochromic anemia with reduced serum iron, reduced transferrin saturation and TIBC with normal serum ferritin. His serum creatinine is 1.9 mg % and his urine 24 hour protein excretion is around 2 g%. His blood sugar profile is controlled on insulin glargine at night and plain insulin thrice before meals. His Hba1c is 6.5. Sleep study showed multiple episodes of sleep apnoea during REM sleep and Doppler examination of lower limbs revealed normal arterial flow. An MRI lumbosacral spine showed mild lumbar canal stenosis.  

Questions:

1) For his shortness of breath and pedal edema, what are the various further options for investigating him in the lines of COPD or heart failure with preserved ejection fraction (HFpEF)  and what factors will make you weigh in further on either of these differentials for his shortness of breath and pedal edema? 

2) What are the available further diagnostic and therapeutic options to manage his: 

a)anemia associated with chronic kidney disease and possible iron deficiency? 

b) proliferative retinopathy with vitreous hemorrhage?

c) HFpEF vs COPD vs angina equivalent?

d) Obstructive sleep apnoea 

e) Lower limb intermittent claudication 

f) Giddiness and near syncope on walking (? Vertebro basilar insufficiency)? 

Which option will you choose for this patient and why? Please discuss the efficacy of each option/intervention quoting in a PICO format from studies that you can find around the efficacy of each intervention. Please share your search strategy for each of the possible interventions.

Please find the MCQs for the same patient prepared by our elective student here https://bmjcaselogvivek.blogspot.com/2020/01/patient-centered-questions-mcqs-for_17.html

3) A 29 year old man with a strong family history of stroke and renal failure develops a fever of unknown origin FUO since last three months and on clinical examination is found to be cachectic with tachypnoea and a large right sided pleural effusion which on aspiration is found to be hemorrhagic and exudative with lymphocytic pleocytosis with normal pleural fluid ADA and negative CBNAAT. 

He also has severe anemia, hypoalbuminemia, hypertension, proteinuria, azotemia, metabolic acidosis, pulmonary edema, bleeding diathesis and is begun on regular hemodialysis. His Echocardiography assessments reveal severe concentric left ventricular hypertrophy LVH with preserved ejection fraction. 

While he's also got good transplant prospects due to the availability of a live related donor (his mother), the bigger challenge is to diagnose his fever and large right sided pleural effusion along with controlling his hypertension and heart failure with preserved ejection fraction HFpEF. 

Questions:

1) What would be your further management plan for diagnosing his FUO and pleural effusion? Would you resort to a therapeutic trial for a commonly suspected infective pathology? What would be the role of a video assisted thoracoscopic biopsy in such a situation? 

2) What could be the possible pathological  reason for his familial renal failure and hypertension with a strong history of hypertension and stroke also in his other family members? 

3) How would you manage his severe anemia? What are the advantages or disadvantages of multiple blood transfusions before renal transplant with regard to graft rejection? What is the role of erythropoetin stimulating agents in patients of dialysis? His iron profile shows increased serum ferritin, reduced serum iron and transferrin saturation. How would you decide if he needs correction for iron deficiency as well? 

4) What are the tests to determine chances of graft rejection prior to renal transplant?

Please find the MCQs for the same patient prepared by our elective student here https://bmjcaselogvivek.blogspot.com/2020/01/patient-centered-questions-for.html?m=1

You can either deposit your answer in the comment box or and email to kimsjbcr@gmail.com (the formal  email address for our journal that can be accessed here https://jbcr.net.in/) and or whatsapp to 9121046928 (this number cannot be called but just messaged with your name and you will receive an acknowledgement). 

Please answer all questions. Please feel to ask and add more questions around each one of these "patient centered questions" as YOUR clarifications and patient centered queries will help us develop further insights and we shall also assess your ability to ask questions (either Socratic or in a PICO format toward critical appraisal). Please feel free to google any  of the terminologies that you don't understand here. For those of you who have seen these current patients please share more information details about them that can enrich our systems thinking about their problem.