Medicine blended assessment biweekly

Answer all questions                                                      

Max Marks: 100 

Submit by:                                

Date: 7/9/2020 9:00 AM 

Below is an online formal question paper to be answered online using all available resources at your online disposal over a period of two days and E logged in a manner demonstrated by past examinees in the link below and the link to your E logged answers shared in the same platform where you obtained the current link that you are viewing. 

Please go through the patient data in the links below:

1)Patient data collected and logged by intern Dr Alekya. 

45 yr old lady who is a housewife and had DM 2 since 5yrs and HTN since 1yr. She  was apparently normal 6months back,used to develop pedal edema on and off  aggravates on walking and relieves on taking rest for which she was taken to nalgonda hospital and the doctor had advised her to decrease the fluid intake and gave some medications.It was associated with shortness of breath grade 3.

5days back she had developed pedal edema which got progressed and developed abdominal distension,facial puffiness associated with decreased urine output,sob even at rest  and chest pain on right side, non radiating with intermittent palpitations.

More here: https://alekyatummala.blogspot.com/2020/09/45-yr-female-with-anasarca.html?m=1

1) What is your complete anatomic and etiologic diagnosis from the data available in the patient's online record linked above? (ignore the provisional diagnosis on admission mentioned in the case report)

2) What are the reasons for her:

Azotemia 

Anemia 

Hypoalbuminemia 

Acidosis 

3) What was the rationale for her treatment plan detailed day wise in the record? 

Particularly mention rationale and  efficacy for some of the drugs administered such as oral and iv bicarbonate? When is iv or oral bicarbonate indicated and why is it contraindicated in certain situations? 

4) What was the indication for dialysing her and what was the crucial factor that led to the decision to dialyze her on the third day of admission? 

5) What are the other factors other than diabetes and hypertension that led to her current condition? 

6) What are the expected outcomes in this patient? Compare the outcomes of similar patients globally and share your summary with reference links. 

7) How and when would you evaluate her further for cardio renal HFpEF and what are the mechanisms of HFpEF in diabetic renal failure patients?

8) What are the efficacies over placebo for the available therapeutic options being provided to her for her anemia? 

What is the utility of tools like the CKD-AQ that assess the frequency, severity, and impact on daily activities of symptoms of anemia of CKD? Is Telegu among the 68 languages in which it is translated? 

10) What is the contribution of protein energy malnutrition to her severe hypoalbuminemia? What is the utility of tools such as SGA subjective global assessment in the evaluation of malnutrition in CRF patients? 

2) A similar patient data as above with diabetes and renal failure with metabolic acidosis and hypoalbuminemia logged by intern Dr Bhavya here https://bhavyayammanuru.blogspot.com/2020/09/aki-secondary-to-uti.html?m=1

Please comment on the differences in the diagnosis, therapy and outcomes in both these two patients. 

Would you agree with the provisional diagnosis shared for this  58 M in the online case report linked above?

What are the findings in the ultrasound of both kidneys? How do you explain those findings? Would it explain the etiology for his renal failure? 

Please feel free to review the literature online before answering the above questions but take care not to plagiarise any of that literature while answering these questions. One can quote only one to two lines maximum from the reference literature and the references and links should be shared along with the quotes or paraphrased information derived from the referenced literature. 

Please check out some active learning discussion around answering this case based question format as well as avoiding plagiarism here https://medicinedepartment.blogspot.com/2020/05/frequently-asked-questions-around-case.html?m=1

Please check out these links to few answers in the past in E log books from our other students around different set of questions:

https://medcases.blogspot.com/2020/05/heart-failure-2.html?m=1

https://virtualmedicalcases.blogspot.com/2020/06/the-dark-side-of-depression.html?m=1

https://caseopinionsbyrollno156.blogspot.com/2020/05/trio-of-paraparesis-cases.html?m=1

For a past online question paper in a patient centered clinical problem solving version please check the link below:

https://medicinedepartment.blogspot.com/2020/01/patient-centered-questions-for.html?m=1

Virtual case bank Dermatology

 70yr Male patient came to opd with c/o lesion associated with itching all over the body since 20days.

Online case record by Dr Deepika Parmar here 

https://pamardeepika24.blogspot.com/2020/08/this-is-online-e-log-book-to-discuss.html?m=1

Offline case presentation by Dr Nikita here 

https://youtu.be/_x5gGPyVQVM

Virtual case bank Rheumatology

 40 year old woman  came to opd with c/o bilateral swelling of lower limbs since 6 months, Shortness of breath since 6 months,joint pains since 4 months, and facial puffiness since one week, decreased urine output since 2 days.

https://sai1120.blogspot.com/2020/08/autoimmune-case.html

Offline case presentation 

https://youtu.be/xqDhMJw8Clw

Medical cognition research and CBBLE timeline 1

Medical cognition is an area of research made popular since this 1998 paper by Vimla Patel as a further development in the field of Medical Informatics particularly to "examine human-computer interaction in medical contexts and computer-mediated collaborative processes."

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC61330/

It was a pleasure getting to know Prof Vimla since 2008 virtually through existing human computer interactive interfaces for social collaboration aka email groups and social media especially through her association with a National body that was developed to further medical Informatics research in India. 

While the above paper used illustrations that were meant to be generalizable as per the prevailing paradigm there was another requirement in "medical cognition" that was evolving and waiting for quite a while having been addressed by other systems of medicine that didn't remain mainstream and that was around "answering multidimensional information needs" in individual patients and this was in someways a harbinger of developing a "case based blended learning ecosystem" aka CBBLE (pronounced "cable") that represented another pathway in medical cognition.  

1998-99 CBBLE journey begins: With one CBBLE team member this began somewhere two decades back with the documentation of the case here:

https://www.giejournal.org/article/S0016-5107(00)70398-1/fulltext

The first author is currently the director of SGPGI, Lucknow as well as VC, KGMU, Lucknow. 

 2000: The same CBBLE team member changed institutes two decades back and shared one more case based experience from Pokhara, Nepal here:

https://pubmed.ncbi.nlm.nih.gov/11762624/

Slowly the realization dawned that individual case based experiences were different from the average data being  represented in Clinical trials where each of these individuals was just a number.

2002: Contrary to what trial data projected, every individual was unique and had unique life trajectories and it was found that medical students were best suited to unearthing these trajectories as documented here: https://www.eubios.info/EJ124/ej124j.htm

Some of these medical students who were now academic faculty, revisited this idea in the last CBBLE paper here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6163835/

2007: It was gradually becoming clearer that current evidence based medicine needed a more meaningful methodology to answer individual patient requirements here: https://pubmed.ncbi.nlm.nih.gov/17683292/

2008: And soon the first conceptual model for current CBBLE was shared here: http://www.ncbi.nlm.nih.gov/pubmed/19018905

It was called "user driven healthcare" UDHC and described a prevalent phenomenon evolving with the internet and the only difference with the later CBBLE appears to be that the term "blended learning" got added to the same process suggesting that the CBBLE had a strong component of offline connection and locality that was blended to requirements of online users. 

The CBBLE idea as a subset of the UDHC phenomenon was to build a Case based reasoning database that could offer any individual patient data a platform for obtaining comparisons between other individual patients who had similar data patterns and then see if near matches of individual trajectories would offer similar outcome trajectories in those group of patients and this was inspired by a seminal paper on case based reasoning linked here: https://pubmed.ncbi.nlm.nih.gov/15533257/

The pursuit of clinical problem solving using online user driven learning was a polymathic pluralistic activity and we derived a lot of lessons from other fields as illustrated in chapters of the UDHC book here 

https://www.igi-global.com/chapter/user-driven-learning-environment-botany/49258

2009: The model could be scaled to the last mile primary care and act as an efficient bridge between primary and tertiary, individual home, community collaborative center and academic institutions as proposed here:   https://pubmed.ncbi.nlm.nih.gov/19811603/

2010-2020--

Many such cases started getting logged by last mile workers in various parts of India particularly West Bengal and they were processed by a CBBLE that fed case based problems to a global forum for conversational learning as shared here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4117104/

The forum was made by global medical and engineering  students and there is more about them in the above article as well as in the UDHC book and journal issues here https://www.igi-global.com/journal/international-journal-user-driven-healthcare/41022 as well as their own web pages 

here: https://www.missionarogya.com/p/mission-and-vision.html?m=1

And here: blog.sbose.in/2012/08/ui-design-considerations-for-user.html?view=timeslide&m=1

2012 the team presented our work in TEDx Kolkata here https://youtu.be/76AVUQOK9LM

The Online links to some currently surviving patient records can be found in the online learning portfolios of the last mile worker users here below:

https://736146.blogspot.com/?m=1

(The number in the URL reflects the area pin code from where the last mile worker operates). 

https://ebpc-udhc-debasishacharjee.blogspot.com/?m=1

These last mile workers had begun a new genre of multilingual, deidentified online patient records that were partially structured and managed in most instances to convey individual patient requirements and their work was further shared globally in published case studies linked below:

The paper below is a collated depiction of cases emailed by some of our last mile workers and how their differently structured patient histories were still useful to develop a learning ecosystem between the offline patient and online healthcare learner and helper. 

https://www.researchgate.net/publication/265050836_Person-centered_healthcare_in_the_information_age_Experiences_from_a_user_driven_healthcare_network

The paper below is a case study that highlights our workflow of sharing "open access patient records with de-identified patient documentation such as doctors’ notes, diagnostic test results and the patient’s perspective" toward improving their outcomes along with students learning outcomes. 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6047727/

The original online patient record blog that was foundational to the published case study is accessible here: https://ebpc-udhc-debasishacharjee.blogspot.com/2017/07/38-year-old-woman-suffering-from-tb.html?m=1

With the steady progress of our last mile workers abilities to create web based logs of patient records the abilities of the medical students in our learning ecosystem remained at par by translating quite a few, perhaps 50-70 of these online patient records into journal publications accessible here https://pubmed.ncbi.nlm.nih.gov/?term=Rakesh+Biswas+

2013 one of the activities of a team member who looked after the editorship of BMJ Case reports was to spread the word about case based learning and how every individual patient was an independent research project and below are links to some of the lectures delivered in 

Manipal http://www.pitt.edu/~super1/lecture/lec50421/001.htm

AMU http://www.pitt.edu/~super1/lecture/lec50661/001.htm

https://www.amu.ac.in/about3.jsp?did=9352

Bhopal PCOR 2014: http://www.pitt.edu/~super1/lecture/lec53081/001.htm

Bangalore 2015 http://www.pitt.edu/~super1/lecture/lec53671/002.htm

Delhi Banga Bhavan  2015 http://www.pitt.edu/~super1/lecture/lec53961/001.htm

2015 was particularly important as one medical college started funding research assistants who were more conversant with Hindi to take this work forward and below are some of their work in their multilingual online learning portfolios 

RA1: Hindi online patient record 

kg83797.blogspot.com/?m=0

RA2: Link to online patient logs:

https://www.blogger.com/profile/06851455361260935925

RA2: Link to one time assessment:

userdrivenhealthcare.blogspot.com/2016/03/assessment-of-patient-information_28.html?m=1

RA3: Link to one time assessment:

userdrivenhealthcare.blogspot.com/2016/03/assessment-of-patient-information_87.html?m=1

RA4: Link to online patient logs:

https://www.blogger.com/profile/14713506954507734603

RA4: Link to one time assessment:

userdrivenhealthcare.blogspot.com/2016/03/assessment-of-patient-information.html?m=1

RA5: Link to online patient logs:

https://www.blogger.com/profile/08543457215724518158

RA5: Link to one time assessment:

userdrivenhealthcare.blogspot.com/2016/03/experience-patients-are-interviewed-by.html?m=1

73 cases in this web based log book  from LNMCH courtesy, research assistant,  Kuldeep Gupta 

globaludhc09.blogspot.com/?m=0

46 cases in this web based log book  from LNMCH courtesy, research assistant,  Kuldeep Gupta

 http://globaludhc07.blogspot.com/?m=0

2016 end saw the migration to another beginning detailed in part 2 here http://medicinedepartment.blogspot.com/2021/06/evolution-of-model-forpatient-centered.html?m=1

Virtual case bank Nephrology

1) Dr Sai Teja - intern 2015  .

A case of 40F with bilateral swelling of lower limbs ,facial puffiness ,sob since 3 months  and joint pains .

https://sai1120.blogspot.com/2020/08/autoimmune-case.html.

2) Dr Nishitha - Intern 2015 .

22 yr old previously healthy man presented with Anasarca, foamy urine and progressive shortness of breath since 2 weeks.

https://nishithatummala006.blogspot.com/2020/08/nishithas-elog.html

3) Dr Yamini - intern 2015 .

   70 year old woman from Chityal, a daily wage worker presented with the complains of Bilateral pedal edema ,Abdominal distension ,Facial puffines ,Dyspnea since 4 days .

https://yaminivallabhu.blogspot.com/2020/07/hello-everyone-im-medicine-intern-and.html?m=1

4) Dr Aashitha - PGY 2 

A case of CKD ON MHD with 

Dypnea at rest since 5 days and  Bilateral pedal edema since 4 days .

https://ashiness92.blogspot.com/2020/07/38-year-old-woman-currently-on.html?m=1.

5) Dr Sindhu - Intern 2015 .

75 yr old female with chief complaints of decreased urine output a/w burning micturition since 15 days and  SOB since 7 days.

https://sindhusailajav.blogspot.com/2020/07/pre-renal-aki-on-ckd.html.

6) Dr Vinod Reddy 2015 intern

28 year old man with CKD on ATT

https://vinodreddy1698.blogspot.com/2020/08/vinod-reddys-elog.html?m=1

7) Dr Alekya 2015 intern 

30Y old male pt  presented to casualty with c/c  of bilateral pedal edema  since 7 days 

-decreased urine output,burning micturition and loss of appetite since 2 days.

-sob since 1day(grade 3-4)

patient got admitted in outside hospital and got treated for urosepsis and AKI.

On presentation to our casualty patient had grade 4 dyspnea with mild confusion.

https://alekyatummala.blogspot.com/2020/08/pulmonary-embolism.html?m=

10)Dr Rangam Sandeep intern 2015

 A 38 year old male came with compliants of dysuria with reduced urine output since four days and pain in hip region since 4 days.

http://rangamsandeep.blogspot.com/2020/06/hello-everyone-i-am-intern-in-medicine.html?m=1

11)Dr Bhargavi Sadam 2015 Intern 

This is a case of 55 yr old male, a farmer who presented with complaints of 

1)pedal edema since 2 months , left sided gradually progressive swelling 

2)pain and swelling in the left gluteal region

http://bhargavisadam.blogspot.com/2020/06/interns-e-log.html

12)Dr Roshini Sathputhe intern 2015

A 65 year old female presented to Opd with chief complaints of 

-Abdominal distension,Diffuse abdominal pain,decreased urinary output,Burning micturition since 4 days 

-Constipation since 2 days

https://roshinisathputhe.blogspot.com/2020/06/medicine-case-e-log.html?m=1

Dr Nikhil Narimeti 2015

24 F with nephrotic syndrome 

https://nikhlilnarimeti.blogspot.com/2020/05/13-may-e-log.html?m=1

Dr Sowmya 2015

40 year old woman, farmer by occupation from Miryalguda, Hypertensive since 1 month, non diabetic, non alcoholic and

Not a smoker presented to our Out Patient Department with the chief complaints of 

Reduced urine output since 2 months

Bilateral lower limbs swelling since 1 month

Lower back ache since 1 month

Facial puffiness since 15 days

https://sowmyamutyala.blogspot.com/2020/06/lady-with-hidden-kidney.html?m=1

Dr Ram Reddy 2015

28 year female in perperium( 20th day post partum) presented to opd with retrosternal pain, and with hemogram report showing low platelet count .

https://somaramreddy.blogspot.com/2020/06/somaramreddy.html?m=1

Virtual case bank Hematology

Hematology 

28 year old man, civil engineer,presented to the casualty with the complains of 

1.Vomitings since 15 days 

2.High colored urine since 4 days 

3.Dyspnea on exertion since 3 days

http://rakeshkumar04.blogspot.com/2020/07/hi-this-is-intern-posted-in-general.html

Dr Soundarya 2015

A 47 year old woman presented to OPD with complaints of difficulty in breathing since 10 days not aggravated or relieved with positional or diurnal variation palpitations since 10 days which were short lasting

https://soundarya1206.blogspot.com/2020/05/hello-all-im-intern-and-here-is-case.html?m=1

Dr Ruchita 2015

15 year old woman with chief complains of

Generalised weakness since 1 month 

Loss of appetite since 1 month 

Headache since 1 month

Yellowish discoloration of sclera and  urine since 1 week

Vomitings since 3 days 

https://ruchithareddy007.blogspot.com/2020/06/e-log.html?m=1

Dr Advitha 2015

60 year old woman with anemia 

https://advitha25.blogspot.com/2020/05/kims-hospitals-narketpally-hello-all-im_23.html?m=1

Virtual case bank Cardiology

CVS 

Presented by Dr Madhuri 2015 batch

A 35 years old man presented with complaints of shortness of breath since 2weeks and pedal Edema since 2weeks after a febrile episode one month prior. More in the E log below:

https://madhur116.blogspot.com/2020/05/on-1452020.html?m=1

http://hitesh116.blogspot.com/2020/05/elog-14th-may-2020.html

Same case JVP video link: https://drive.google.com/file/d/1Gr2xuU5bcPUbNmQaPjVIavwn1m-FK7gr/view?usp=drivesdk

Same case Echo video link: https://drive.google.com/file/d/1K9Fk66l6c79ziOF-dIYQ3vDlGbSavlr7/view?usp=drivesdk

PG intern offline Case presentation and discussion video here:https://youtu.be/4YnJZwbp0eE


2) Presented by Dr Himabindu 2015 batch

A 55 years old woman with chest pain, palpitations and shortness of breath since two months:

https://himabindu5.blogspot.com/2020/05/hello-everyone.html

Offline intern PG discussion around 55F with chest pain, palpitations and

shortness of breath since two months:

https://youtu.be/Rrc5r1MFZ2Y (part 1)

https://youtu.be/zzxTuzdUvwA (part 2)

3) Presented by Dr Saikiran 2014 batch

30 years old man with bilateral pedal edema extending up to knee, dyspnea on exertion since 15 days and he also complains of palpitations since 1 year.

https://saikiranpatnam.blogspot.com/2020/05/medicine-case.html?m=1

https://vidya8829.blogspot.com/2020/05/hello-all-im-intern-and-here-is-case.html?m=1

The active learning session linked below was initiated by the treating unit PG before the treating unit intern collated the patient information into this E log above 


https://medicinedepartment.blogspot.com/2020/05/re-active-learning-session-on-global.html?m=1

Post active learning global online session with our global CBBLE the same PG presented this patient offline locally here 

https://youtu.be/2GJicww_JJg

And here https://youtu.be/Z10RgxICaCY

Dr Rubeena 2015

A 46 years old male patient came with complaint of chest pain for 30 minutes yesterday evening and shortness of breath on exertion. 

https://rubeenamaheenruby.blogspot.com/2020/06/internship-medicine-posting.html?m=1

A few common questions for the students

1) Where are the different anatomical locations for the cause of the shortness of breath and palpitations for each of these patients?

2) What is the most likely pathology and etiology in that anatomical location?

3) What are the diagnostic and therapeutic options in such situations and what is the efficacy of each option/intervention?

4) Please share questions that come to your mind upon going through each of the cases.