Assessor's inputs to Fortnightly 1st Feb 2020 INTERNAL ASSESSMENT EXAM FOR 1st and 2nd YEAR PG STUDENTS

This is the version of the question paper with answers from the examinees aka respondents or responders (and other random online visitors) along with multiple assessor inputs to those answers. 

For a cleaner and initial version of the question paper accessed by the examinees please click here: 

https://medicinedepartment.blogspot.com/2020/01/fortnightly-feb-2020-internal.html?m=1

The second assessor has provided some inputs on the assessment process and the first assessor too before s/he actually started assessing the examinee inputs and to quote below:

"[2/6, 11:21 PM] Well I think most of the first respondent's answers were pretty much copy paste with no reference. Also very bookish but I also felt the questions were too long sir.
[2/6, 11:22 PM]  In fact the lack of awareness of what referencing a source or even appraising literature means they couldn't grasp the idea in the first place.
[2/6, 11:23 PM] However the answers were informative and to the point.
[2/6, 11:25 PM] The first assessor's comments are still only corrective. Like telling the responder to cite a reference or not to copy more than 1 line from a source or to appraise the literature accordingly. These are basic stuff which the responder should know in the first place and the assessor's comments should ideally be focused on a discussion around the answer rather than these corrections."

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) 

Answers by the examinees:

First year Medicine resident (deidentified, let's call him/her "second responder"

Thanks please find the first assessor's inputs inline below: 

On Feb 2, 2020 12:33 PM, secondresponder@gmail.com> wrote:

Question 1

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) 

A) Pseudocyst is related anteriorly to head of pancreas

Not in continuity with either greater or lesser sac 

In continuity with main pancreatic duct

In this case as pseudocyst is in close proximity with jejunum hence cystojejunostomy

First assessor: 

This is an original answer from you unlike the others below which are not (but that is again partly due to the nature of the questions) and this exercise is about how to share publicly in a useful and safe manner that also teaches us to beware of plagiarism.

Coming to the first original answer did you find time to discuss this with the radiologist? Let me know if they agree or have anything more to add.  

Also did you answer all these questions below? 

"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?"

B)

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

Did not find any evidence suggesting use of antibiotics in pseudocyst without any evidence of sepsis.

Please share your search key words. Did you use "antibiotic prophylaxis pseudocyst"?

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

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

Assessor's inputs: You didn't answer the question above? Also you confused by marking the answer below as (c) when it appears to actually attempt to answer question (d) 

Ok I just noticed you sent the answer to (c) in a different email/post

C) After diagnostic needle aspiration guided by computed tomography and/or ultrasound, 11 infected pseudocysts in ten patients were treated nonoperatively by percutaneous catheter drainage and intravenously administered antibiotics. Nine infected pseudocysts resolved after 11 to 37 days (mean, 21 days) with no recurrences at follow-up 16 to 42 months (mean, 24.4 months) later. All were confirmed by Gram's stain, culture, and elevated amylase levels. Ten of the pseudocysts were acute; one was chronic; five were polymicrobial; six had a single organism. There were no major complications. There was one failure when a pancreatic abscess developed in a patient who died following operative drainage. There was one successful palliation of a postoperative-infected pseudocyst in a patient with an obstructing nonresectable carcinoma of the head of the pancreas. A trial of percutaneous catheter drainage is indicated in patients with infected pancreatic pseudocysts.

Percutaneous Drainage of Infected Pancreatic Pseudocysts

Assessor's inputs: unfortunately the above doesn't really explain what you plainly copy pasted and assumes your audience will just get it from the data of an abstract that appears to be a case series! 😅

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

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

Assessor's input (wrongly indicated as 'c' while answering?) 

 C) Fifty-seven assessable patients were randomly assigned in a double-blind fashion to therapy with 1 g of cefonicid intravenously (iv) or intramuscularly (im) 1 hr before surgery only or 2 g of cefoxitin iv or im 1 hr before surgery and 2 g every 6 hr for 24 hr.

Assessor butting in:

This answer starts rather abruptly and catches the audience unawares.

Perhaps you are discussing the evidence  in terms of a single RCT to begin with? Your answer needs to clarify that with an introduction. 

Groups were comparable in terms of underlying diseases. Samples for blood culture were obtained immediately before and after surgery and at 8:00 A.M. on the first and second postoperative days. No blood cultures were positive. Two of 30 patients receiving cefonicid developed wound infections (6%). Two of 27 patients receiving cefoxitin developed wound infections, and one developed an intraabdominal abscess (11%). No significant adverse effects were noted. The results suggest cefonicid may be an effective prophylactic antibiotic for bowel surgery. 

Not sure how it answers the actual question about role of prophylactic antibiotics in intestinal obstruction. The treating unit PGs, on informal clinical audit had mentioned that they were administering antibiotics to the patient also as they suspected intestinal obstruction and hence the origin of the question. A study that may have answered it would have been antibiotics vs placebo? Are you able to find one? 

Prophylactic antibiotics for elective colorectal surgery or operation for obstruction of the small bowel: a comparison of cefonicid and cefoxitin. - PubMed - NCBI

Assessor's input: Above is not how you reference or cite an article. The correct citation is 

"Fabian TC, Mangiante EC, Boldreghini SJ. 

Prophylactic antibiotics for elective colorectal surgery or operation for obstruction of the small bowel: a comparison of cefonicid and cefoxitin.

Rev Infect Dis. 1984 Nov-Dec;6 Suppl 4:S896-900

Downloaded from https://www.ncbi.nlm.nih.gov/m/pubmed/6395280/

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

Not answered ?

Pancreatic pseudocyst (3 marks) 

Assessor's inputs: There appears to be a lot of copy paste (aka generous borrowing of quotes till they can't be called quotes any longer) without any attribution. Strangely in traditional handwritten paper based offline exams where just one assessor is tortured with these answers, this may even be lauded with good marks because the question was essentially asking for it. 😅

Pancreatic pseudocyst

Pseudocysts form when the cells of the pancreas become inflamed or are injured and pancreatic enzymes start to leak. Leaking of the enzymes harms the tissue of the pancreas. Pancreatic pseudocysts are different from true pancreatic cysts. Both cysts and pseudocysts are collections of fluid. A true cyst is a closed structure. It has a lining of cells that separates it from the nearby tissue. A pseudocyst isn’t closed and doesn’t have a lining of epithelial cells separating it from the nearby tissue.

Etiology-

Pancreatic pseudocysts may start after an episode of sudden (acute) pancreatitis. People with chronic pancreatitis can also get pseudocysts. They may also form in conditions that cause long-term pancreas inflammation (chronic pancreatitis).

Gallstones

Chronic alcoholism

• Pancreas injury or trauma
• Pancreas infection
• Pancreatic tumor
• High levels of calcium in your blood
• Very high levels of blood fats (cholesterol)
• Pancreatic damage from medicines
• Autoimmune diseases

Clinical features

• Stomach pain. 
• Fever
• Swollen belly
• Nausea and vomiting
• An abdominal mass detected on physical exam
• Severe pancreatitis may also cause dehydration and low blood pressure.

Treatment

Treatment for the pseudocyst may vary. Many pseudocysts will go away with supportive care.

Short note 3:

ERCP 

Endoscopic retrograde cholangiopancreatography (ERCP) is a combined endoscopic and fluoroscopic procedure in which an upper endoscope is led into a second part of the duodenum, making it possible for passage of other tools via the major duodenal papilla into the biliary and pancreatic ducts. Contrast material may be injected in these ducts, allowing for radiologic visualization and therapeutic interventions when indicated.

Indications

ERCP indications include obstructive jaundice, biliary or pancreatic ductal system disease treatment or tissue sampling, suspicion for pancreatic cancer, pancreatitis of unknown cause, manometry for sphincter of Oddi, nasobiliary drainage, biliary stenting for strictures and leakage, drainage of pancreatic pseudocysts, and balloon dilation of the duodenal papilla and ductal strictures. Sphincterotomy is indicated in cases of the sphincter of Oddi dysfunction or stenosis, difficulty with biliary stenting or accessing the pancreatic duct, biliary strictures, bile duct stones, bile sump syndrome following choledochoduodenostomy, choledochocele, and in poor surgical candidates with ampullary carcinoma.

Pancreatic necrosectomy

Pancreatic necrosectomy is the surgical procedure used in the management of acute necrotising pancreatitis, a condition characterised by the inflammation of the pancreas.

The primary indication for performing a pancreatic necrosectomy, whether it be open or laparoscopic, is the presence of infected pancreatic necrosis. It can also be performed in the case of sterile pancreatic necrosis with associated deterioration of the patient’s clinical status.

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)

First responder answers 

a.H/o right sided weakness with memory impairment- left MCA

Left medial rectus palsy - 3rd cranial nerve
Absent sensation over left half of face - 5th nerve
Scanning speech - cerebellum
Vomitings +
PICA territory - lateral medullary syndrome ?

Dementia due to temporal lobe involvement :MCA territory infarct

Behavioural abnormalities , depression,apathy , dyskinesia would help in further localising

Assessor's queries/inputs: How would depression apathy help in localizing? 

Dementia due to temporal lobe? 

b. B- Bilateral MCA infarct 

With Right  PICA infarct 

Assessor's inputs/queries: What anatomical areas are involved that are supplied by MCA and PICA 

c) In the setting of acute stroke, MRA is useful for determining the severity of stenosis, vascular occlusion, and collateral flow. CE MRA and 3D TOF techniques have relatively high sensitivity and specificity in differentiating surgical from nonsurgical carotid stenoses. Three-dimensional TOF MRA is quite sensitive and specific for the evaluation of intracranial proximal stenoses and occlusions. Two-dimensional PC MRA is useful for determining collateral flow patterns in the circle of Willis. MRA is also useful in the determination of stroke etiologies such as dissection, fibromuscular dysplasia, vasculitis, and moya moya. Currently, MRA is relatively insensitive to the detection of stenoses in distal intracranial vessels but this detection will improve with new MR hardware and software.

No I will not advise for this patient .

Assessor's inputs: Please always share the reference link and never quote more than one line from that link 

Short notes:

1. Weber’s syndrome (Neurology) (2)

First responder:

Weber syndrome - ipsilateral 3rd nerve plasy with contralateral hemiparesis due to infarct in midbrain  by occlusion of posterior cerebral artery or bifuracting branches of basilar artery
Clinical findings mainly eyeball is down and out ipsilateral lateral squint. Ptosis present. Pupil dilated and fixed as LPS nerve supply is disrupted
It is usually unilateral and affects many structures
If it involves substantia nigra - Parkinson features are seen
Corticospinal-contralateral hemiplegia
Corticobulbar- contralateral lower facial muscle weakness.

Management: antiplatlets for secondary prevention and physiotherapy.

1. Cerebrovascular disease etiologies (2)

First responder: 

etiology of CVA: 
Infarct due to thrombosis or embolic phenomenon 
Hemorrhage

Risk factors : 
Daibetes ,HTN,smoking ,obesity,hyperlipidemia, atherosclerosis ,
Cardiovascular diseases: atrial fibrillation,mitral valve prolapse ,family history of stroke ,trauma ,

1. Aspirin and stains in CVD prevention: 

1. evidence in PICO format (3)

Not answered

1. Multiple infarct dementia (3)

First responder:

multiple infarct dementia is also called as vasular infarct

Vascular dementia is widely considered the second most common cause of dementia after Alzheimer's disease, accounting for 5 percent to 10 percent of cases.
Symptoms include: 

Confusion

Disorientation

Trouble speaking or understanding speech

Physical stroke symptoms, such as a
sudden headache

Difficulty walking

Poor balance

Numbness or paralysis on one side of the face or the body

Controlling risk factors that may increase the likelihood of further damage to the
brain’s blood vessels is an important treatment strategy

Assessor's inputs: This short note appears to be simplified into a patient's handout. Please always share reference links and use quotes. 

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)

First responder:

Differential daignosis : community acquired pneumonia:
Viral /bacterial /fungal / atypical .

Right sided pneumonia with subsequent ARDS

M/c/c cause of viral pneumonia- influenza
Bacterial- streptococcus pneumoniae
Gram negative- H.influenzae

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

First responder:

According to AIIMS 2019 guidelines :
Pneumonia leading to ICU admission
Antibiotic of choice is beta lactams+ macrolides preferred than beta lactams plus fluoroqunilones

As there are no structural lesions of lung,aspiration history ,old age , no need of psuedomonal and aneraobic coverage

How would you prevent contagion? (2)

First responder:

Wearing mask 
Isolation of patient 
Hand wash techniques after touching patient 

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

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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. 

Utilizing mobile user driven E logs of patient data to improve hospital and community healthcare services

Project Title: Utilizing mobile user driven E logs of patient data to improve hospital and community healthcare services through real time patient centered clinical audit with a collaborative blended learning ecosystem of patients, students and health professionals

Introduction:

There is a striking deficiency in medical learning competencies attained by medical faculty and students that are hardly ever reflected on or brought to notice in the course of caring for their patients. A biochemist may not know how the HbA1c values that s/he regularly facilitates in his lab is actually utilized by the clinician and patient and the clinician may not realize how the HbA1c values are actually generated in the lab.

All medical students, doctors and health professional faculty need to have cognitive competencies to take care of primary requirements of a rapidly growing patient population but our current curriculum may not allow it's participants to realize why they need to learn what they are learning, how this knowledge may be applied by them to meet their patient requirements and if their training can allow them to answer queries that arise naturally and not as a result of an outdated curriculum that compels them toward non-contextual rote memorization.

This dichotomy and gap between health education and practice badly affects current day healthcare where a large proportion of health professionals are in danger of becoming apathetic to patient requirements.

To resolve the above mentioned problems in current medical education and healthcare, Medical council of India MCI has recently proposed a focus on developing competency in medical students is a small step to move forward in the direction of producing doctors confident and competent enough to meet the needs of our population.1

Building on it further, we propose a patient-centered E log project with a ‘learning team’ comprising of Medical students and experienced faculty engaged in blended collaborative learning around ‘individual patients.

Methods:

We shall utilize a mixed methods study design. In the course of a learning session for 3 years, a team of faculty and students from various departments in the hospital will be exposed to regular 'patient encounters' in the inpatient and outpatient wards of Kamineni Institute of Medical sciences, Narketpally. This team shall capture deidentified patient-data at the 'point of care' (in the form of history, images of clinical findings as well as radiology and lab data) and then subsequently share them to the online E-log platform specially created to facilitate communication and discussion to learn around the patient.

The patients selected will have a sufficient level of clinical complexity likely to generate maximum learning outcomes in terms of patient centered learning questions which is detailed here.2

The collected 'patient data' after processing in the discussion forum can be published online as a 'patient centered online health record' PCOHR in freely available publishing platforms suggested by our past published "online patient records" linked to our student's "online learning portfolios" here.3,4,5,6

Subsequently the prepared 'online health record' web link for each individual patient is shared on to our online social-media based processing forum that has a current global membership of 1500+ members, many of who actively participate in solving patient problems posted to the forum.  

All this patient centered 'data collection and processing' activity shall be subsequently documented in 'patient centered online health records' PCOHRs such as the one's shared above and this online record 7 and demonstrates how research publications are generated from them such as this.8

Results/Expected Outcomes:

This mixed methods study design will document results through qualitative thematic analysis of student-faculty learning insights, qualitative insights on patient-health-outcomes and quantitative estimates in terms of the number of validated participatory learning inputs contributed by each student and faculty and quantitative estimates of patient health in terms of QoL. The results of the impact evaluation of our PCOHR educational intervention strategy will be validated as per currently known paradigms. 9 An additional feature of note in our project is the utilization of online learning portfolios of students and faculty, which are generated partly automatically online from their documented participatory learning conversations in our currently active online case based blended learning ecosystem CBBLE. These portfolios will be thematically analyzed to assess the results/learning-outcomes of each faculty and student's learning activity. The portfolio based quantitative learning points generated around each patient will be compared with the results/outcomes obtained in terms of their respective patient improvement using quantitative QoL estimates (SF36 etc.).

Discussion and Implications for Practice:

The 'patient-centered learning' process will further involve learning feedback provided to the patient's primary caregiver by our 'case based blended learning learning ecosystem CBBLE managers and then noting the results in comparison to a 'control group' of patients whose providers receive no CBBLE feedback. Our hypothesis toward the expected outcome of this project is that the CBBLE team as well as their patients will have respectively better learning as well as QoL outcomes than the control group-team. A CBBLE nurtured and scaled in an appropriate patient centered manner can go a long way toward improving health professional learning as well as improving patient outcomes and the combination of the two will be instrumental in augmenting national capacity building and transforming healthcare.

SWOT Analysis:

Strengths: Promising solution to current felt need that can bridge gaps in healthcare learning competencies as well as address patient outcome complexities.

Weaknesses: Quasi-experimental and complex study design and consequent potential of study sample selection bias. (Workarounds: ensure transparent and accountable online documentation of entire process that is naturally subject to external peer review in real time)

Opportunities: Potential to scale into a sustainable model of practice based learning toward

improving patient outcomes.

Threats: Participant motivation leading to study attrition, patient privacy and confidentiality (Workarounds: regular motivational meets with participants of both groups with real-time transparent documentation of the interaction that transpires between all the stakeholders)

References:

1. https://www.quora.com/Can-we-form-a-system-to-grade-the-doctors-as-per-their-competency
2. http://www.pcori.org/research-we-support/pcor/
3. https://virtualmedicocases.blogspot.com/2018/03/9-year-old-girl-had-developed-fever.html?m=1
4. http://keerthiereddy.blogspot.com/2017/12/spastic-quadriparesis-mnd.html?m=1

5. http://allabouthyponatremia.blogspot.com/2018/11/heart-failure-presenting-as-hyponatremia.html?m=1

6. http://derangedmedicine.com/cor-pulomonale-and-acute-exacerbation-of-copd/
7. http://userdrivenhealthcare.blogspot.com/2016/03/udhc-case-study-from-online-patient.html?m=1
8. http://casereports.bmj.com/content/2014/bcr-2013-202916.full
9. http://en.wikipedia.org/wiki/Impact_evaluation

Other ongoing similar programs in our Institute:

Blended learning electives:

http://promotions.bmj.com/jnl/bmj-case-reports-student-electives-2

Past Experience:

Developing a Case-Based Blended Learning Ecosystem to Optimize Precision Medicine: Reducing Overdiagnosis and Overtreatment

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6163835/

Online patient records and online resident learning portfolios:

https://medicinedepartment.blogspot.com/2019/01/utilizing-web-based-log-books-of-post.html?m=1

More:

http://www.ncbi.nlm.nih.gov/pubmed/?term=rakesh+biswas

http://scholar.google.com/citations?hl=en&user=Sc3HgGAAAAAJ&view_op=list_works&sortby=pubdate

Other References/Bibliography:

Patient centered research and learning:

http://www.pcori.org/research-we-support/pcor/

Clinical Complexity:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2327227/pdf/wpa010001.pdf

http://www.ajmc.com/publications/issue/2012/2012-9-vol18-n9/impact-of-clinical-complexity-on-the-quality-of-diabetes-care/3

Clinical complexity and teaching learning competencies: http://www.wpba4gps.co.uk/fileadmin/user_upload/secure/mindmaps/PDF_files_for_Competency/Medical_Complexity__Detail_.pdf

Quasi Experimental studies and identifying causation between intervention and effect:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1380192/pdf/16.pdf

https://www.academia.edu/1482786/How_investigating_mediators_and_moderators_helps_explain_intervention_effects

Utilizing web based log books of post graduate residents to create online patient records and online resident learning portfolios

This is a lecture discussion session beginning on a Sunday with this social media post to a closed group of online post graduate residents and faculty about an upcoming session on Tuesday.

First post: 5:00 PM to 5:30 PM

"Welcome to this Tuesday session that promotes using "web based log books" to not only help current PGs manage their paper based log books in a genuine manner but also enables them and the entire medical college to utilize these as a learning and decision making tool around our patients.

We hope that this will enable a large number of our faculty man power in clinical physiology, clinical anatomy, clinical microbiology, clinical pathology, clinical pharmacology and Community Medicine to actually regularly review and help us with useful ideas around our patients.

This Tuesday session is a blended learning exercise and we begin this "flipped" classroom by sharing some basic knowledge around "web based log books" and online learning portfolios as done in other parts of the globe and India.


You may notice some "medical education" buzz words here, such as "flipped classroom, blended learning, portfolio based learning etc and I have been slightly liberal with these terminologies as everyone in this group (including the PGs) are medical educators.

I have included in this online group everyone possible in the faculty (at least those whose numbers I have and those who may not leave midway) and the Principal, Medical Superintendent, Vice principal and most HOds are here other than the post graduate residents.

Two resources around web based log books shared below. Keeping all this to the bare minimum to avoid information overload

Indian article on Portfolio based learning 

Western article on portfolio based learning

Will await all of your queries, thoughts and inputs on the above

Deafening silence till 8:45PM when the online instructor for the online component of this blended learning session (yours truly)  decides to share his second post

Second post (8:45 PM to 10:45 PM)

To take you to the point where you may be able to appreciate how and why web log books can be used as a valuable learning tool that can positively impact patient outcomes in this hospital I shall try to begin this journey from our current existing paper based log books. Shared below are some images of its key pages each of which I shall discuss separately again below regarding their importance and how web-logbooks can improve on them.

Figure 1

Figure 1 shows the first important page that you see in your log book and it appears to be all about yourself as a PG. What would you like to write about yourself has been suggested although I am not sure if that actually tells us a lot about what you have already attained in your previous years of graduation in terms of your learning. It just tells us that you have cleared some memory based exams to reach your current position.

Figure 2

Figure 2 shows the next page in your log book which is about evaluation of your clinical work day wise. Now considering that you will be working everyday as a PG 365 days a year, I guess the number of pages are grossly inadequate? 🤔😬


Now there are three more type of slots in your log book meant to assess the kind of presentations you have made in terms of 'Journal review,' seminar and case presentation. Perhaps in our regular Tuesday sessions, from now on, we can incorporate the elements of 'journal review' along with the case presentation and discussion seminar that you have already been doing around the cases that you have been presenting here.'

So now that you know the university log book requirements well, we just need to come to the most important part of our session and that is how would expanding this paper based log book workflow into a web based log book (and online learning portfolio) be useful for you or the institution. Before I move ahead I would need your valuable inputs on what would be your thoughts on the above.

There's one response from one of the Professors in this online group next day at 10:45 AM:

"Micro lesson of medical education will be of very effective ?"

My brief response at 11:40 AM:

👍

Again continuing with the online posts

Third post at 11:40 AM:

Continuing the one way lecture (aka talking to myself) I now share a few links below to a few web based log books ( aka Online learning portfolios) done by current PGs in the Indian Medical education system.

[ 11:42 AM] Here's an online log book from a PG in RIMs Ranchi, India where you can notice the first page of the bio data although not the other pages like day to day work or case presentations or seminars or journal reviews although you can see a lot of his seminar based publications in the past done in his UG and early PG years


Online learning portfolio on research gate 

[11:42 AM] Here's an online log book (web based portfolio) from a PG in AIIMS Delhi and again you will notice that it contains much less than what is recommended in the paper based format.


Online learning portfolio in LinkedIn 





[11:42 AM] Here's another more dynamic and impactful online learning portfolio from another PG in AIIMS Delhi


Online learning portfolio in quora

Here you will notice that he has included a case presentation and even a useful seminar answer to someone's query (which shows that his seminar can actually have a wider impact among global users and readers of his portfolio.

He has off course included a lot of other content, which shall we just say is not a part of his syllabus and that brings us to the important point that Online portfolio based learning is not just bound by the narrow confines of a university syllabus which is again one of the reasons some universities who are way behind in creating academic impact will have little to do with it.

(11:42 AM)So why are we trying to be any different and why are we striving hard to move beyond our university requirements?

Simply because as PGs when we chose our profession we had a dream of making an impact and reaching out to a wider audience.


11:42 AM] This impact can only happen if all of us who are part of the medical college hospital based learning ecosystem strive to improve together. In the beginning straddling two different tools could appear daunting rather than a value addition but we must realize that this is not to burden ourselves additionally but to actually lessen our burden. Any day and in any way if you feel burdensome you can feel free to make an anonymous post and share and we shall try to address that issue without being judgemental. The online learning portfolio ecosystem affords us the luxury of both anonymity as well as transparency.

[11:42 AM]: Here's another online portfolio from one of our own Institute PGs

http://derangedmedicine.com/about/


That promises to be about some of the stuff that is also prescribed in his paper based log book. He has used his online learning portfolio well till now and also published a few of that content in journal formats.


[11:42 AM]: Here's another online portfolio from another PG from our institution who has made it an anonymous portfolio and we are perfectly fine with that as every individual has a right to express him/herself in his/her own manner.

https://virtualmedicocases.blogspot.com/?m=1


The most important thing that differentiates a portfolio from a paper based log book is that the portfolio brings out the personality of the individual and the point here is that one can guage and admire an author's personality just through his/her reflective writings even if one is unable to identify the author.

Some book authors are able to write under pseudonyms and yet successfully make a global impact.


[11:42 AM]: Another learning portfolio from our PG with case presentations and her thesis plan. This portfolio is not anonymous although there is no bio page yet.

http://keerthiereddy.blogspot.com/?m=1


[11:42 AM]: Another learning portfolio from our PG which is all about her thesis and details about her thesis cases. This can be very useful to obtain learning inputs on your thesis on a case by case basis.

http://allabouthyponatremia.blogspot.com/?m=1

We continued this in further online samples of E logs from our institution as well as another institution with arguably one of the best post graduate training programs in the country with dedicated offline faculty and a number of global faculty who respond to the E logs by the post graduate residents by helping out to solve the problems presented in the E logs with experiential and critically appraised evidence.

Also coming up in the next post is a video about what actually transpired in the actual offline component of this blended learning flipped classroom.

Meanwhile here are a few videos of classroom sessions with our post graduates doing Journal reviews, case presentations and seminars as prescribed in their log book curriculum:

Case presentation

Journal review  1

Journal review 2

Elective presentation in CMC Vellore