Tuesday, January 28, 2025

Project Altered sensorium clinical complexity outcomes NKP 2025

Themes explored in the case below discharged yesterday:


Diagnostic uncertainty:

Clinical features suggestive of acute meningitis in a patient of metabolic syn with trunkal obesity, parotidomegaly etc as part of the metabolic phenotype.

Hemorrhagic lumbar puncture inconclusive




Cranial MRI suggestive of blood or pus, interpreted due to REDUCED DIFFUSION IN TRIGONES OF B/L LATERAL
VENTRICLES as ? CHRONIC INTRA VENTRICULAR BLOOD COLLECTION OR PUS

Past traumatic brain injury 8 years back for which craniectomy was done and similar episode suggestive of meningitis 4 years back.





Therapeutic uncertainty:

Empirical pharmacological and non pharmacological interventions  

EMR summary (with defensive medicine themes due to the diagnostic and therapeutic uncertainty):

Age/Gender : 45 Years/Male
Address :
Discharge Type: Referred
Admission Date: 27/01/2025 04:59 AM

Diagnosis:

ALTERED SENSORIUM SECONDARY TO ?SEPTIC ENCEPHALOPATHY B/L FLUID FILLED LATERAL VENTRICLES [?BLOOD ?PUS]
CHRONIC INFARCTS IN LEFT FRONTAL REGION S/P CRANIOTOMY
K/C/O HTN, DM II


Case History and Clinical Findings PATIENT WAS BROUGHT TO CASUALTY WITH H/O FEVER SINCE 2 DAYS
HEADACHE SINCE 7 DAYS
ALTERED SENSORIUM SINCE YESTERDAY 5PM C/O SLURRING OF SPEECH YESTERDAY
C/O B/L LOWER LIMB WEAKNESS SINCE YESTERDAY HISTORY OF PRESENT ILLNESS
PATIENT WAS APPARENTLY ASYMPTOMATIC 2 DAYS BACK THEN HE DEVELOPED FEVER HIGH GRADE WITH CHILLS, INTERMITTENT, ASSOCIATED WITH HEADACHE - DIFFUSE. PATIENT WAS ABLE TO DO HIS REGULAR ACTIVITIES UPTO YESTERDAY EVENING, THEN
DEVELOPED GIDDINESS, NOT ASSOCIATED WITH LOSS OF CONSCIOUSNESS,
INVOLUNTARY MOVEMENTS, FROTHY, TONGUE BITE. PASSED URINE CONSCIOUSLY AS HE WAS UNABLE TO MOVE DUE TO GIDDINESS. TAKEN TO OUTSIDE HOSPITAL, TALKED TO ATTENDERS AFTER HOSPITAL ADMISSION, THEN DEVELOPED ALTERED SENSORIUM
NO H/O VOMITINGS, LOOSE STOOLS
 

PAST HISTORY
H/O SIMILAR COMPLAINTS IN THE PAST
K/C/O HTN SINCE 10 YRS ON TELMA H 40/125, CINOD 10 MG K/C/O TYPE II DM SINCE 10 YRS ON METFORMIN 500MG OD

PERSONAL HISTORY :
OCCUPATION : GOVT EMPLOYEE NORMAL APPETITE BOWEL:REGULAR
MICTURITION : NORMAL NO KNOWN ALLERGIES
ADDICTIONS : ALCOHOLIC LAST INTAKE 5 DAYS BACK SMOKING NO
BETEL LEAF(PAN) - NO
FAMILY HISTORY : NOT SIGNIFICANT


GENERAL EXAMINATION :
NO PALLOR, ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY, EDEMA BP: 140/90 MMHG
PR: 89 BPM
RR: 20 CPM
SPO2: 99%
GRBS- 301 mg/dL SYSTEMIC EXAMINATION
CVS- SI, S2 HEARD, NO THRILLS, NO MURMURS RS- BAE +, NVBS
ABDOMEN- SOFT, NON TENDER
CNS- PATIENT IS DROWSY AROUSABLE SPEECH - SLURRED
CRANIAL NERVES - NORMAL SENSORY SYSTEM - NOT ELICITED GCS - E2V3M3
MOTOR SYSTEM - RT LT TONE UL NORMAL NORMAL
 

LL INCREASED INCREASED POWER CANT BE ELICITED RIGHT LEFT
REFLEXES B 2+ 2+
T 2+ 2+ S - -
K - -
A - -
P FLEXION FLEXION


NEUROSURGERY REFERRAL DONE ON 27/1/25,I/V/O CHRONIC BLOOD COLLECTION IN LATERAL VENTRICLES ON MRI BRAIN, ADVISED NO ACTIVE NEUROSURGICAL INTERVENTION NEEDED AS OF NOW. CONSIDER NEUROPHYSICIAN OPINION.
OPHTHALMOLOGY REFERRAL DONE ON 27/1/25 I/V/O RAISED ICT CHANGES, ADVISED NO RAISED ICP CHANGES NOTED AS OF NOW



Investigation

CSF: Hemorrhagic (microscopic findings and biochemical analysis missing from the EMR summary)

COMPLETE URINE EXAMINATION (CUE) 27-01-2025 05:50:AM
COLOUR Pale yellow APPEARANCE Clear
REACTION Acidic SP.GRAVITY 1.010 ALBUMIN + SUGAR +++
BILE SALTS Nil BILE PIGMENTS Nil PUS CELLS 3-6
EPITHELIAL CELLS 2-4 RED BLOOD CELLS Nil CRYSTALS Nil
CASTS Nil
AMORPHOUS DEPOSITS Absent OTHERS Nil
LIVER FUNCTION TEST (LFT) 27-01-2025 05:50:AM
Total Bilurubin 3.24 mg/dl 1-0 mg/dl
 

Direct Bilurubin 0.76 mg/dl 0.2-0.0 mg/dl
SGOT(AST) 21 IU/L 35-0 IU/L
SGPT(ALT) 19 IU/L 45-0 IU/L
ALKALINE PHOSPHATASE 97 IU/L 128-53 IU/L
TOTAL PROTEINS 7.3 gm/dl 8.3-6.4 gm/dl
ALBUMIN 4.2 gm/dl 5.2-3.5 gm/dl
A/G RATIO 1.36
BLOOD UREA 27-01-2025 05:50:AM 46 mg/dl 42-12 mg/dl


SERUM CREATININE 27-01-2025 05:50:AM 1.4 mg/dl 1.3-0.9 mg/dl SERUM ELECTROLYTES (Na, K, C l) 27-01-2025 05:50:AM
SODIUM 130 mmol/L 145-136 mmol/L
POTASSIUM 3.4 mmol/L 5.1-3.5 mmol/L
CHLORIDE 94 mmol/L 98-107 mmol/L



ABG 27-01-2025 05:57:AM
PH 7.40
PCO2 27.0
PO2 103
HCO3 16.4
St.HCO3 19.0
BEB -6.7
BEecf -7.5
TCO2 33.1
O2 Sat 97.8
O2 Count 33.1


HBsAg-RAPID 27-01-2025 06:05:AM Negative
Anti HCV Antibodies - RAPID 27-01-2025 06:05:AM Non Reactive HEMOGRAM

HAEMOGLOBIN 12.7gm/dl
TOTAL COUNT 23,000cells/cumm NEUTROPHILS 87%
LYMPHOCYTES 03%
 

EOSINOPHILS 01%
MONOCYTES 09% BASOPHILS00% PCV 36.1vol %
M C V87.6fl M C H 30.9pg
M C H C 35.3% RDW-CV 13.5% RDW-SD 47.1fl
RBC COUNT 4.12 millions/cumm PLATELET COUNT 1.99 lakhs/cu.mm RBC Normocytic normochromic

WBC Increased in count with Neutrophilia PLATELETS Adeqaute
HEMOPARASITES No hemoparasites seen
IMPRESSIONNormocytic normochromic blood picture with Neutrophilic leukocytosis


MRI BRAIN PLAIN
CRANIOTOMY CHANGES ARE SEEN IN THE RIGHT SUPERIOR PARIETAL REGION. CRANIOTOMY CHANGES ARE SEEN IN THE RIGHT FRONTAL AND INFERIOR PARIETAL REGION
SMALL AREA OF REDUCED DIFFUSION IS SEEN IN THE LEFT CEREBELLAR HEMISPHERE MEASURING 11MM S/O CYTOXIC EDEMA COULD BE DUE TO INFECTION OR ACUTE INFARCT FLUID FILLED LEVELS WITH REDUCED DIFFUSION IN TRIGONES OF B/L LATERAL
VENTRICLES- COULD BE - CHRONIC INTRA VENTRICULAR BLOOD COLLECTION OR PUS
COLLECTION
MODERATE SIZED CHRONIC INFARCT IN LEFT INFERIOR TEMPORAL REGION
SMALL AREAS OF NEUROPARENCHYMAL LOSS WITH SURROUNDING GLIOSIS IN LEFT SUPERIOR TEMPORAL LOBE, LEFT ANTERIOR FRONTAL LOBE, RIGHT POSTERIOR FRONTAL LOBE - S/O CHRONIC INFARCT
BASAL GANGLIA AND THALAMI ARE NORMAL
CRANIO VERTEBRAL AND CERVICO MEDULLARY JUNCTIONS ARE NORMAL SELLA, PITUITARY AND PARASELLAR REGIONS ARE NORMAL
 

STALK AND HYPOTHALAMUS ARE NORMAL. POSTERIOR PITUITARY BRIGHT SPOT IS NORMAL

2D ECHO NO RWMA
TRIVIAL TR/AR/MR NO PAH
SCLEROTIC AV : NO AS/MS IAS- INTACT EF = 58% RVSP = 32+5 = 37MMHG GOOD LV SYSTOLIC FUNCTIONS
NO DIASTOLIC DYSFUNCTYION IVC SIZE [1.40 CM] COLLAPSING NO PE , LV CLOTS


Treatment Given(Enter only Generic Name)


1.] IV FLUIDS NS @ 100ML/HR WITH 1AMP OPTINEURON
2.] INJ DEXAMETHASONE 6MG IV/TID
3.] INJ MONOCEF 2GM STAT >2GM IV BD
4.] INJ DOXYCYCLIN 100MG IV/BD
5.] INJ LEVIPIL 500MG IV/BD
6.] INJ THIAMINE 600MG IV/STAT > 200MG IV/BD
7.] INJ PAN 40MG IV/OD
8.]INJ ZOFER 4MG IV/SOS
9.]INJ PCM 1GM IV/SOS
10.]INJ HAI S/C TID ACC TO GRBS
11.] GRBS 7 POINT PROFILE MONITORING
12.] MONITOR VITALS 2ND HRLY
13.] RT FEEDS - 100ML MILK 4TH HRLY
- 50ML WATER 2ND HRLY
14.] INJ.VANCOMYCIN 2GM IV/BD
15.] INJ NEOMOL 1GM /SOS


Advice at Discharge


REFER TO HIGHER CENTRE
 

THE PATIENT Attenders HAS BEEN EXPLAINED ABOUT THE CONDITION OF THE PATIENT IN THEIR OWN UNDERSTANDABLE LANGUAGE AND REQUIREMENT OF IMMEDIATE NEUROPHYSICIAN AND NEUROSURGERY INTERVENTION AS ADVISED BY NEUROPHYSICIAN AND IS BEING REFERED TO HIGHER CENTRE I/V/O SAME.

Discharge Date Date: 27/1/25 Ward:ICU
Unit: V

Here's a summary, key words, thematic analysis with coding, categorization, and learning insights from the provided case report:

Summary
A 45-year-old male patient presented with fever, headache, altered sensorium, and slurred speech. He had a history of metabolic syndrome, hypertension, and type 2 diabetes. The patient underwent various investigations, including MRI brain, which showed chronic blood collection or pus in the lateral ventricles. He was treated with empirical antibiotics, antifungals, and supportive care. The patient was discharged with advice to seek higher center care for neurophysician and neurosurgery intervention.

Key Words
1. Altered sensorium
2. Metabolic syndrome
3. Meningitis
4. Encephalopathy
5. Diagnostic uncertainty
6. Therapeutic uncertainty
7. Empirical treatment
8. Neuroimaging
9. Chronic blood collection
10. Pus collection

Thematic Analysis with Coding
1. *Diagnostic Uncertainty* (DU): The case highlights the challenges in diagnosing altered sensorium, with multiple possible causes, including meningitis, encephalopathy, and metabolic disturbances.
2. *Therapeutic Uncertainty* (TU): The treatment approach was empirical, with a broad-spectrum antibiotic and antifungal coverage, due to the uncertainty surrounding the underlying cause.
3. *Complex Patient Profile* (CPP): The patient's metabolic syndrome, hypertension, and type 2 diabetes complicated the diagnosis and treatment.
4. *Neuroimaging Findings* (NIF): The MRI brain revealed chronic blood collection or pus in the lateral ventricles, which guided the treatment approach.
5. *Multidisciplinary Care* (MDC): The case emphasizes the need for collaboration between healthcare professionals, including neurologists, neurosurgeons, and intensivists.

Categorization
1. *Clinical Presentation*: Altered sensorium, fever, headache, and slurred speech
2. *Diagnostic Approach*: Neuroimaging (MRI brain), laboratory investigations (blood cultures, CSF analysis)
3. *Therapeutic Approach*: Empirical antibiotics, antifungals, and supportive care
4. *Patient Profile*: Metabolic syndrome, hypertension, type 2 diabetes

Learning Insights
1. *Diagnostic uncertainty*: Altered sensorium can have multiple causes, and a thorough diagnostic approach is essential.
2. *Empirical treatment*: In cases of diagnostic uncertainty, empirical treatment with broad-spectrum antibiotics and antifungals may be necessary.
3. *Multidisciplinary care*: Collaboration between healthcare professionals from different specialties is crucial in managing complex patients.
4. *Neuroimaging*: MRI brain can provide valuable information in diagnosing and managing altered sensorium.
5. *Patient education*: Educating patients and their families about the importance of seeking higher center care and adhering to treatment plans is essential.


Past data on the NKP Altered sensorium outcomes project:







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Sunday, January 19, 2025

Hypersplenism outcomes in NKP, a CBBLE UDLCO project

Summary


The hypersplenism outcomes Project begins with a conversation that revolves around a 13-year-old female patient diagnosed with pancytopenia secondary to hypersplenism and moves on to also dwell on the insights gained in the previous similar qualitative patient data already archived in our database. The discussion involves a group of medical professionals sharing their insights, workup, and treatment plans for the patient. They also share similar cases from their experience, highlighting the complexities of diagnosing and managing hypersplenism.

Key Words
1. Hypersplenism
2. Pancytopenia
3. Splenomegaly
4. Bone marrow biopsy
5. Splenectomy
6. Medical education
7. Case-based learning




Conversational learning Transcripts:

[17/12/2024, 10:31]rb: MOPD 13F studying 8th school with fever and pancytopenia with a clinical massive splenomegaly and delayed sexual maturity joins our other older 21M patient with the same issue and adds to the other two 20F with similar issues we have in our follow up, one of who also had a splenectomy and used to work in@⁨Metacognitist Mover and Shaker1⁩'s previous College


[17/12/2024, 10:42] rb : @⁨Communicating Learner 1N23⁩ @⁨ 2022 Kims Med Pg⁩ any update on his fever chart following yesterday's admission?👇


@⁩ his uncle says he's actually 21 (although he looks 13) and they may have said 19 earlier

[18/01, 13:59]SR Medicine: @⁨Pushed Communicator 1N22⁩ @⁩ sir,  even confirmation of hypersplenism mandates bone marrow's normal or hyperplastic state....


[18/01, 16:41] rb: 👆@⁨SR Medicine⁩ @⁨ 2022 PG Medicine⁩ @⁨2020 Kims PG Med⁩ @⁨Prof ⁩ just found this online trace of the patient we discussed offline today in the rounds, possibly while evaluating her for the first time in OPD just before her first admission.

Here's her previous EMR summary:

Age/Gender : 13 Years/Female
Address :
Discharge Type: Relieved
Admission Date: 17/12/2024 04:59 PM

Diagnosis:

PANCYTOPENIA SECONDARY TO HYPERSPLENISM ?

CHRONIC ILLNESS

SHORT STATURE - PROPORTIONATE (BMI: 14.6 KG/MSQ.)


Case History and Clinical Findings


PT C/O FEVER SINCE 1 WEEK PT C/O COUGH SINCE 1 WEEK PT C/O COLD SINCE 1 WEEK
PT WAS APPARENTLY ASYMPTOMATIC 1 WEEK BACK THEN DEVELOPED FEVER, HIGH GRADE WITH CHILLS, COUGH WITH SPUTUM, WHITISH, MUCOID, SCANTY, NON BLOOD TINGED, NON FOUL SMELLING.
NO H/O BURNING MICTURITION, PAIN ABDOMEN, VOMITTING NO H/O BLEEDING TENDENCIES
NO H/O BREATHLESSNESS, EASY FATIGUABILITY PAST HISTORY:
N/K/C/O DM,THYROID DISORDERS, HYPERTENSION, EPILEPSY, CAD, CVA PERSONAL HISTORY:
DIET: MIXED
BOWEL AND BLADDER: REGULAR ALLERGIES: NONE
ADDICTIONS: NONE
FAMILY HISTORY: INSIGNIFICANT GENERAL EXAMINATION:
 

BP: 90/60 MMHG PR: 86 BPM
RR: 16 CPM TEMP: AFEBRILE
NO PALLOR, ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY, EDEMA SYSTEMIC EXAMINATION:
CVS: S1S2+ NO MURMURS RS: BAE+ NVBS
P/A: SOFT, NT BS+, Moderate  SPLENOMEGALY 

CNS: NFND
ENDOCRINOLOGY OPINION TAKEN ON 20-12-24 I/V/O LESS HEIGHT AND WEIGHT; INAPPROPRIATE SECONDARY SEXUAL CHARACTERISTICS
ADV: CHRONOLOGICAL AGE> BONE AGE> HEIGHT AGE> WEIGHT AGE BONE MARROW ASPIRATION + BIOPSY
TREAT UNDERLYING CONDITION GOOD NUTRITION
HIGH PROTEIN DIET PHYSICAL Exercises


COURSE: A 13 YEAR OLD PT CAME WITH C/O FEVER SINCE 1 WEEK, COUGH SINCE 1 WEEK, COLD SINCE 1 WEEK
VITALS: BP: 90/60 MMHG PR: 86 BPM RR: 16 CPM TEMP: AFEBRILE
ON FURTHER EVALUATION PT WAS DIAGNOSED AS PANCYTOPENIA SECONDARY TO HYPERSPLENISM ? CHRONIC ILLNESS SHORT STATURE - PROPORTIONATE (BMI: 14.6 KG/MSQ.)PT WAS PLANNED FOR BONE MARROW BIOPSY AND ASPIRATION FOR FURTHER EVALUATION. ADVICED TO FOLLOW UP AFTER 1 WEEK. PT WAS DISCHARGED IN HEMODYNAMICALLY STABLE CONDITION.
Investigation
COMPLETE URINE EXAMINATION (CUE) 17-12-2024 10:48:AM
COLOUR Pale yellowAPPEARANCE ClearREACTION AcidicSP.GRAVITY 1.010ALBUMIN TraceSUGAR NilBILE SALTS NilBILE PIGMENTS NilPUS CELLS 2-4EPITHELIAL CELLS 2-3RED BLOOD CELLS NilCRYSTALS NilCASTS NilAMORPHOUS DEPOSITS AbsentOTHERS Nil
BLOOD UREA 17-12-2024 10:48:AM 21 mg/dl 42-12 mg/dlSERUM CREATININE 17-12-2024
10:48:AM 0.4 mg/dl 1-0.5 mg/dl
 

LIVER FUNCTION TEST (LFT) 17-12-2024 10:49:AMTotal Bilurubin 0.58 mg/dl 1-0 mg/dlDirect Bilurubin 0.16 mg/dl 0.2-0.0 mg/dlSGOT(AST) 41 IU/L 31-0 IU/LSGPT(ALT) 16 IU/L 34-0
IU/LALKALINE PHOSPHATASE 306 IU/L 369-54 IU/LTOTAL PROTEINS 7.9 gm/dl 8-6 gm/dl

ALBUMIN 4.2 gm/dl 5.4-3.8 gm/dl
A/G RATIO 1.16SERUM ELECTROLYTES (Na, K, C l) 17-12- 2024 10:49:AM
SODIUM 138 mmol/L 145-136 mmol/L
POTASSIUM 4.1 mmol/L 5.1-3.5
mmol/L
CHLORIDE 99 mmol/L 98-107 mmol/L
T3, T4, TSH 18-12-2024 12:12:PM
T3 1.29 ng/ml 1.87-0.87 ng/ml
T4 10.23 micro g/dl 12.23-6.32
micro g/dl
TSH 0.86 micro Iu/ml 5.36-0.34 micro Iu/ml USG REPORT:
IMPRESSION: BORDERLINE SPLENOMEGALY
Treatment Given(Enter only Generic Name)
SYP ASCORYL LS 10 ML PO/TID
Advice at Discharge
BONE MARROW ASPIRATION + BIOPSY GOOD NUTRITION
HIGH PROTEIN DIET PHYSICAL EXCERCISES
Follow Up
REVIEW TO GM OP AFTER 1 WEEK FOR BONE MARROW BIOPSY AND ASPIRATION OR SOS
When to Obtain Urgent Care
IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR ATTEND EMERGENCY DEPARTMENT.
Preventive Care
AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE,DONOT MISS MEDICATIONS. In case
of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact:  For Treatment Enquiries Patient/Attendent Declaration : - The medicines prescribed and the advice regarding preventive aspects of care ,when and how to obtain urgent care have been explained to me in my own language
SIGNATURE OF PATIENT /ATTENDER SIGNATURE OF PG/INTERNEE SIGNATURE OF ADMINISTRATOR SIGNATURE OF FACULTY
Discharge Date
Date:20-12-24
Ward:FMW
Unit:II


[18/01, 16:43] rb: To quote:

"In 1955, Dameshek (7) summarized that hypersplenism should be diagnosed in the presence of four conditions: i) monolineage or mutilineage peripheral cytopenias; ii) compensatory hyperplasia of bone marrow; iii) splenomegaly; and iv) correction of cytopenias after splenectomy. Although these four conditions do not always apply to all cases, they have been commonly cited in the literature, and are important in the diagnosis of hypersplenism."



[18/01, 17:30] SR Medicine: Appreciate PG @⁨ 2022 PG Medicine⁩ for very good documentation of all the workup sir, I myself recollected the discussion after endocrine consultation, and Kudos🙌 to you @⁨ for creating a data retrievable platform and being able to use it as and when necessary....


[19/01, 19:14] rb: Speaking of data retrieval in the context of this current 14F while we still don't have her case report made, we do have, as part of our unexplained hypersplenism and splenectomy outcomes project, a similar case of a 14M with hypersplenism who also got operated, logged by our previous PG @⁨2020 Pg Med here: https://raveen07.blogspot.com/2022/08/14m-massive-splenomegaly-case-of.html?m=1 and presented in 2023 Jan 26 CPD here: https://youtu.be/XSugyqRrU84?feature=shared and later revisited as a retrospective here: https://userdrivenhealthcare.blogspot.com/2023/11/pajr-jarvis-reports-final-entry-for.html?m=1

with hemoglobinopathy which is again a close differential in the current patient for which we deferred her bone marrow aspiration biopsy after yesterday's discussion and decided to await her Hb electrophoresis report along with iron profile perhaps empirically see the response to injection Vitamin B12 as per @⁨2020 PG Med⁩ 's readings.

Here's another slightly older patient of hypersplenism in our follow up who also had a splenectomy and is doing well https://snehalmvs.blogspot.com/2023/02/22f-pancytopenia.html?m=1 and it's possible that she may have had a similar profile when she was 14! She was also included in our clinical complexity in anemia project with Dr Pavani as the PI (case 17 amidst all the 50 cases archived here) : https://pavani2021.blogspot.com/2024/07/meta-ai-driven-thematic-analysis-nkp-in.html?m=1
Further retrospective on the anemia clinical complexity project: https://medicinedepartment.blogspot.com/2024/07/y24narketpally50n-clinical-complexity.html?m=1


Other than the above recent similars with hypersplenism is a 21M still looking for someone who may do his splenectomy and we came close to getting his RBC scan that suggests splenic sequestration after we referred him to Gandhi Medical College once our anesthesiology rejected him as too complex for a rural medical college! Currently he's being worked up further in hematology, NIMs Punjagutta. More about him here: https://pajrcasereporter.blogspot.com/2024/11/19m-opd-puo-massive-splenomegaly-short.html?m=1


Thematic Analysis
_Codes_
1. Hypersplenism diagnosis
2. Treatment options
3. Case-based learning
4. Medical education
5. Patient management
6. Splenectomy outcomes

_Themes

1. _Hypersplenism Diagnosis and Management_: The conversation focuses on diagnosing and managing hypersplenism, highlighting the importance of bone marrow biopsy and splenectomy.

2. _Case-based Learning_: The discussion involves sharing similar cases, emphasizing the value of case-based learning in medical education.

3. _Medical Education and Patient Management_: The conversation underscores the importance of medical education in patient management, particularly in complex cases like hypersplenism.

Learning Points


1. _Importance of Bone Marrow Biopsy_: Bone marrow biopsy is crucial in diagnosing hypersplenism and guiding treatment plans.

2. _Splenectomy Outcomes_: Splenectomy can be an effective treatment option for hypersplenism, but outcomes may vary depending on individual cases.

3. _Value of Case-based Learning_: Case-based learning is essential in medical education, allowing healthcare professionals to share experiences and insights.

4. _Complexity of Hypersplenism Diagnosis_: Diagnosing hypersplenism can be complex, requiring careful evaluation of patient symptoms, laboratory results, and imaging studies.



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Tuesday, January 14, 2025

UDLCO CRH Project: Medical educational drivers to over-testing and overtreatment captured in peer to peer online learning groups

Summary


The conversation revolves around a medical case scenario discussing a 53-year-old female patient with hypertension, diabetes, and rheumatoid arthritis. Peer learners share their approaches to diagnosing and treating the patient, and the group moderator critiques the answers, highlighting the importance of addressing the underlying pathology and the limitations of current medical practices.

Key Words
1. Medical education
2. Over-testing
3. Overtreatment
4. Hypertension
5. Diabetes
6. Rheumatoid arthritis
7. Medical cognition
8. Evidence-based medicine
9. Artificial intelligence




Conversational learning Transcripts (non Socratic dialogue around a probable non real patient simulation scenario:

 [06/01, 19:44] group moderator : A 53 year old female, with medically controlled diabetes, under metformin 500 bd, is suffering from morbid hypertension. The average diurnal PBP being 180/100

The patient is on telmisartan/metoprolol 40/50 in combination. 
The patient is a patient of clinically diagnosed RA under methotrexate 7.5 bi weekly.

Renal profile is normal with no dyselectrolemia, creatinine 0.8
Hb 10
TLC WNL
Thyroid profile WNL.
Lipid profile WNL

How to approach the case to diagnose the underlying pathology and how to escalate the anti hypertensives? 

Please opine and oblige...


[07/01, 03:04] peer learner 1: How I might have approached the case-
Firstly if her bp still averages 180/100 after telmi/metopr, then I wld firstly admit her & start on injectable diuretics (Lasix 10mg TDS later tapering to BD & so on) in conjunction with Nicardia 20 mg SOS if BP still persists above 140/90 mm Hg after her lasix & Telmi/Metoprolol.. 
In RA, body is under oxidative stress too which probably also plays a role in HTN, so I'll provide her with some antioxidant combination & MVI too..

Then if her bp starts returning to baseline I'll discharge her by switching her bp med to a readily available standard combination of Chlorthalidone-Telma-Am tablet🤔 also since due to oxidative stress & inflammation assoc with RA & Morbid Htn on top of that, she is at severe risk of any Cerebrovascular or Cardiovascular adversity, I'll advice her to switch from metformin to glifozins which are known to be protective in cardiac related scenarios..."

Clinical problem question scenario over.

Question to:

Medical cognition (integrating medical education and practice) learners and enthusiasts:

Can you identify the medical cognition drivers to over-testing and overtreatment captured in this real (but deidentified) peer to peer online learning scenario.

Can you as a first step begin by pointing out the non evidence based interpretations of medical data that arises out of too much focus on hypothetical pathophysiologies and too less on RCT data?

On Wed, 8 Jan 2025, 09:18 ap wrote:

Happy New Year! This is a great concept! Might you frame it like NEJM  and personalize it for co-productive community medicine? This way you could broaden your impact as you  are making a puzzle (medical mystery)  to solve by all. This appeals to all and can bring in cultural relevance, local barriers etc…


Date: Wed, 8 Jan 2025, 09:52 rb

Reminded of the prolific framings of such similars I used to engage in around 2000 at one column called "images in clinical medicine"! 

Unfortunately while they have pubmed traces the full text may have disappeared from everywhere else: https://pubmed.ncbi.nlm.nih.gov/15055875/

I guess I moved to framing them rather loosely in blogspot as there's no rigorous peer review to get there but it may still thrive asynchronously through human life long post publication peer review if not AI bot user driven processing!


On Sun, 12 Jan 2025, 17:24 rk> wrote:

This is very fascinating. It will take some time but I'm trying to model all these decisions in a causal reasoning graph. Lets see if that representation is able to quickly point out where the mistakes were.

Quick question -



On Tue, 14 Jan 2025, 19:43 rb > wrote:
My answer is also a critique of the answer given by peer learner 1.

The question by the original poster OP was:

How to approach the case to diagnose the underlying pathology and how to escalate the anti hypertensives? 

Peer learner 1 in his answer chooses to ignore the first half of the question and simply jumps to fix the hypertension!

One answer to the first component of the question, "How to approach the case to diagnose the underlying pathology"


 is: It's easy if one can spot the phenotype!

Here's how the phenotype of a metabolic syn patient may look like (as in the opening clinical image in the link): https://medicinedepartment.blogspot.com/2024/10/clinical-complexity-project-individual.html?m=1

Essentially it's about accumulating a lot of adipocytes around the trunk!

There are some western repositories offering a loose eye ball estimated visual representation of body fat such as here: 

We have much more visual images in our departmental patient centered metabolic syn data base that needs an AI to cluster them in the above format hopefully in the near future and we are even currently wondering how to register all our images in Wikimedia commons (if anyone could help to work out the logistics)!

Coming back to the pathophysiology:

These adipocytes are very metabolically active and a key driver to the underlying pathophysiology of hypertension through endothelial inflammation and fibrosis causing vessel stiffness.

The second component of the answer is the trickiest and also would be the most impactful area we can work on with the help of AI driven PICO format evidence generators for each therapeutic choice!

But again more importantly one is likely to realise that there's not much evidence for any of the BP lowering pharmacological interventions in improving long term organ failure outcomes and it's logical that eliminating the risk factors for development of trunkal obesity is more likely to be a scientific cure than simply producing a cosmetic effect on the BP using vasodilators or diuretics!

Thematic Analysis
_Codes_
1. Medical education
2. Case scenario discussion
3. Diagnostic approach
4. Treatment options
5. Critique of medical practices
6. Evidence-based medicine
7. Artificial intelligence

_Themes_

1. _Medical Education and Cognition_: The conversation highlights the importance of medical education and cognition in shaping medical practices.

2. _Diagnostic Approach_: The discussants share their approaches to diagnosing the patient, emphasizing the need to address the underlying pathology.

3. _Treatment Options and Limitations_: The conversation critiques the treatment options presented, highlighting the limitations of current medical practices and the need for evidence-based medicine.

4. _Role of Artificial Intelligence_: The discussants mention the potential role of artificial intelligence in improving medical practices and generating evidence-based guidelines.

Learning Points

1. _Importance of Addressing Underlying Pathology_: Medical practitioners should focus on addressing the underlying pathology rather than just treating symptoms.

2. _Limitations of Current Medical Practices_: Current medical practices may not always be evidence-based, and practitioners should be aware of these limitations.

3. _Need for Evidence-Based Medicine_: Evidence-based medicine is crucial in ensuring that medical practices are effective and efficient.

4. _Potential Role of Artificial Intelligence_: Artificial intelligence can play a significant role in improving medical practices and generating evidence-based guidelines.

 



 Image from: https://medicinedepartment.blogspot.com/2024/01/medical-cognition-cpd-jan-25-2024theme.html?m=1



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Saturday, January 4, 2025

UDLCO : Journal club with author on capacity building mental well being and medical professionalism in medical students

Summary


The conversation revolves around a study on medical students' experiences with professionalism, mental well-being, and coping strategies. The study used qualitative phenomenological methods and focus group discussions to gather insights. The discussants praise the study, ask questions about methodology, and highlight the importance of addressing mental well-being issues in medical education.

Key Words
1. Medical students
2. Mental well-being
3. Professionalism
4. Coping strategies
5. Qualitative research
6. Focus group discussions
7. Medical education


Conversational Transcripts:

03/01, 14:49] +97 Congratulations 🎉🎈 very nice study

[03/01, 15:10] +96: Really insightful dear colleague!



[03/01, 20:34] rb: The sampling diversity is intriguing!

To quote:

"Sampling represented diverse backgrounds (with 27 females, 18 fifth-year students, and 30 Malays)."


[03/01, 20:41] rb: Liked this diagram very much 👇



[03/01, 20:53] +96: Thank you. This statement from Abstract is well elaborated in the subsequent section. e.g Characteristics of participants in the FGD:
Purposeful sampling was used to select the 40 partici-
pants, who were medical students from various years,
comprising both males and females from diverse racial
backgrounds (see Table 5). Most participants were female
(67.5%), fifth-year students (45%), and Malay (75%). The
homogeneity of the participants, who were all undergrad-
uate medical students, was relevant to the study’s focus.


[03/01, 22:16]rb: Thanks

Reading further I came across these two apparently disparate paragraphs that needs your help to bring together:

"The FGDs were conducted synchronously online using Zoom©. Participants were required to keep their web cameras on during the sessions, allowing the moderator (principal author) to observe nonverbal cues such as facial expressions, eye contact, and body language."

"Text Interpretation (Step 1): The authors read and re-read the texts."

Query:

How was the synchronous zoom session data converted to text?

How were the non verbal cues factored into the interpretation?


[03/01, 23:02] +96: Thank you. Although in the wake of responding to and or satisfying reviewers’  queries we ought to omit a few details (pertinent for readers), but i still believe and affirm that reading in full the paper in general and the section of  ‘Data analysis and robustness’ in particular will clear it. As an inductive coding approach was adopted for data
analysis, allowing codes to emerge directly from the
data without a predefined framework.  Best wishes.


[03/01, 23:30] +96: Voice to text transcripts conversion manual- non verbal.   Cues were looked for (if any) nothing there/ insignificant.


[04/01, 10:15]rb: Nice having a journal club with the author. 
👏👏

Look forward to do this more often. Wishing you more such papers 👍

Perplexity inputs:

The study "Unveiling the interplay of medical professionalism, mental well-being and coping in medical students" explores how medical students' experiences with professionalism, coping strategies, and mental well-being interact. Using qualitative phenomenological methods, the researchers conducted focus group discussions with 40 students to gather insights into their challenges and coping mechanisms.Critical Appraisal:
  • Study Design: The qualitative approach is appropriate for capturing nuanced experiences but may lack generalizability due to the small sample size and purposive sampling.
  • Results: The findings highlight significant themes around mental well-being issues and coping strategies, indicating a complex relationship between these factors and professionalism. However, the reliance on self-reported data may introduce bias.
  • Conclusion: The study effectively underscores the need for targeted interventions in medical education to enhance student support systems. Future research should address limitations by including larger, more diverse samples to validate findings
The study identified two main themes regarding mental well-being (MWB) among medical students:
  1. Mental Well-Being Issues: This theme highlights persistent mental health challenges faced by students, including stress and anxiety related to their educational environment.
  2. Happiness: This theme illustrates factors that contribute to sustaining well-being, such as social support and positive experiences within their training.
These findings emphasize the complex interplay between coping strategies, professionalism, and MWB, suggesting a need for targeted interventions to support students effectively

The study recommends several interventions to support medical students, focusing on enhancing mental well-being and professionalism. Key recommendations include:
  1. Targeted Support Programs: Develop programs that address mental health challenges and provide coping strategy training, emphasizing resilience and stress management.
  2. Peer Support Systems: Establish peer mentoring initiatives to foster social support, encouraging students to share experiences and coping mechanisms.
  3. Mindfulness and Well-Being Workshops: Implement workshops that teach mindfulness practices and self-care strategies to promote positive coping.
  4. Curriculum Integration: Integrate discussions on mental well-being and professionalism into the medical curriculum to raise awareness and normalize seeking help.
These interventions aim to create a supportive educational environment that nurtures both the mental health and professional development of medical students.


Thematic Analysis
*Codes*
1. Study methodology
2. Mental well-being issues
3. Professionalism
4. Coping strategies
5. Medical education
6. Research limitations
7. Interventions for support

*Themes*
1. _Study Methodology_: The conversation touches on the study's methodology, including the use of qualitative phenomenological methods and focus group discussions.
2. _Mental Well-being Issues_: The discussants highlight the importance of addressing mental well-being issues in medical education.
3. _Professionalism and Coping Strategies_: The conversation explores the complex interplay between professionalism, coping strategies, and mental well-being.
4. _Medical Education_: The discussants emphasize the need for targeted interventions to support medical students' mental well-being and professional development.
5. _Research Limitations_: The conversation notes the study's limitations, including the small sample size and reliance on self-reported data.

Learning Points
1. _Importance of Addressing Mental Well-being_: Medical education should prioritize addressing mental well-being issues to support students' professional development.
2. _Need for Targeted Interventions_: Targeted interventions, such as peer support systems and mindfulness workshops, can help support medical students' mental well-being.
3. _Complex Interplay between Professionalism and Mental Well-being_: The relationship between professionalism, coping strategies, and mental well-being is complex and requires further research.
4. _Limitations of Qualitative Research_: Qualitative research, while providing rich insights, may have limitations, such as small sample sizes and reliance on self-reported data.




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