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Tuesday, March 16, 2021
Monday, March 15, 2021
Medicine paper for March 2021 bimonthly blended assessment
Answer all questions
Max Marks: 100 (10 marks for each answer)
Submit by:
Date: 16/02/2021 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 days and E logged in a manner demonstrated by past examinees in the link here https://
medicinedepartment.blogspot. com/2021/02/blended-bimonthly- assessment-dec-2020.html?m=1 And here is a sample answer paper from the last exam here: https://ashiness3.blogspot.com/2020/11/bimonthly-asses sment-for-month-of.html?m=1 please note that every logged answer paper should contain the link to this current "assignment/question paper" page and the patient context for each answer as well as avoid plagiarism as illustrated in the sample answer paper. A sample answer to the last question around sharing your experiences can be seen here: https://onedrive.live.com/view.aspx?resid= 4EF578BAE67BA469!4180&ithint= file%2cdocx&authkey=! AOy7BpRTn42DBMo Questions:
1) Please go through the patient data in the links below and answer the following questions:
a). What is the problem representation of this patient and what is the anatomical localization for his current problem based on the clinical findings?How specific is his dilated superficial Abdominal vein in making diagnosis?
b) What is the etiology of the current problem and how would you as a member of the treating team arrive at a diagnosis? What is the cause of his hypoalbuminemia?Why is the SAAG low?
c)Will PT,INR derangement preceed hypoalbuminemia in liver dysfunction??Share reference articles if any!
d)What is the etiology of his fever and pancytopenia?
e)Can there be conditions with severe hypoalbuminemia but no pedal edema? Can one have hereditary analbuminemia and yet have minimal edema? Please go this article https://www.
f) What is the efficacy of each of the drugs listed in his current treatment plan
QUESTION 2
45year old female with abdominal distension
a). What is the problem representation of this patient and what is the anatomical localization for her current problem based on the clinical findings?
b) What is the etiology of her refractory ascites and pleural effusion? and how would you as a member of the treating team arrive at a diagnosis?
c) Approach to a patient with ascites?Clinically is there any way to differentiate pre hepatic, post hepatic and hepatic causes?
d)Causes of budd chiari syndrome?Why did the patient undergo bone biopsy?
d) Management strategies for refractory ascites and Budd chiari syndrome? Share the potential advantages and disadvantages of Peritoneal dialysis catheter placement in refractory ascites?
e) What is the efficacy of each of the drugs listed in his current treatment plan
f)What is the current outcome?and what could be the etiology of her current outcome?
QUESTION 3
55year old male with SOB and abdominal distension,orthopnea
a). What is the problem representation of this patient and what is the anatomical localization for his current problem based on the clinical findings?
b) What is the etiology of his ascites? and how would you as a member of the treating team arrive at a diagnosis?Chart out the sequence of events!
c)What is the efficacy of each of the drugs listed in his treatment plan?
d)What are his current outcomes ?
QUESTION 4
4)Please go through the thesis presentation below and answer the questions below by also discussing them with the presenter
a)What was the research question in the above thesis presentation?
b) What was the researcher's hypothesis?
c)What is the current available sensitivity and specificity of SAAG in diagnosis of etiology of ascites
5) Journal club questions on Ascites theme
a) Please identify the study design and outcomes in the article linked here https://www.ncbi.nlm.nih.
b) Please download the CASP diagnostic study checklist here https://casp-uk.net/casp-
c) Please evaluate this randomized controlled trial on different techniques at ascitic tap here: https://pubmed.ncbi.nlm.nih.
Sunday, March 7, 2021
2017 to 2021 Eco friendly Medicine department sample conferences
Low cost eco friendly conferences, workshops, training courses are conducted all the year round by the medicine department as per the mandate of our CBBLE research project toward continuing medical education and integrating it with medical practice.
More about Tabula rasa and our CBBLE projects in the article links below:
2021 Eco friendly Conference sample link:
Conference title: Patient centred clinical problem solving 2021
Workshop Title: Chronic diarrhoea and Malabsorption syndrome
2020 Eco friendly Conference sample link:
Conference title: Patient centred clinical problem solving 2020
Workshop Title: Urosepsis in presence of comorbidities and clinical complexity
2019 Eco friendly Conference sample link:
Conference title: Patient centred clinical problem solving 2019
Workshop Title: Altered sensorium in presence of comorbidities
2018 Eco friendly Conference sample link:
Conference title: Patient centred clinical problem solving 2018
Workshop Title: Syncope in presence of comorbidities
2017 Eco friendly Conference sample link:
Conference title: Patient centred clinical problem solving 2017
Workshop Title: Cyclical and non cyclical chronic mastalgia
Original link to conference platform:
More about Tabula rasa and our CBBLE projects in the article links below:
Bera, K., Seth, B., & Biswas, R. (2013). Conversational learning among medical students: harnessing the power of web 2.0 through user driven healthcare. Annals Of Neurosciences, 20(2).
Pathania, M., Chaturvedi, A., & Biswas, R. (2013). Medical Student Introduction to ‘Patient Centred Healthcare' Through a ‘Constructivist' Learning Session in Cardiology: A Cross Sectional Evaluation. International Journal of User-Driven Healthcare (IJUDH), 3(4), 37-49. doi:10.4018/ijudh.2013100106
Biswas, T., Price, A., Chandra, S., Datta, A., & Biswas, R. (2012). Conversational Learning in Medical Education: Clinical Problem Solving Around Chronic Persistent Headache. International Journal of User-Driven Healthcare (IJUDH), 2(2), 12-23. doi:10.4018/ijudh.2012040103http://www.igi-global.com/
Podder, V.; Dhakal, B.; Shaik, G.U.S.; Sundar, K.; Sivapuram, M.S.; Chattu, V.K.; Biswas, R. Developing a Case-Based Blended Learning Ecosystem to Optimize Precision Medicine: Reducing Overdiagnosis and Overtreatment. Healthcare 2018, 6, 78.
Full text here:https://www.ncbi.nlm.nih.gov/
2021 Ecofriendly regular asynchronous case conferences
2021:
Conference title: Patient centred clinical problem solving 2021Workshop Title: Chronic diarrhoea and Malabsorption syndromeActive participants:Dr Amit Taneja, Faculty Medical College, Wisconsin
SK Biswas, Faculty, Medical College, Jinan University, Guangzhou
Aadipta Ghosh, MBBS Intern, IQ City Medical College Durgapur
Sai Charan Kulkarni , MD Medicine PGY1, KIMs, Narketpally
Dr Faraz, MD Microbology, PGY1, KIMs, Narketpally
Aditya Samitinjay, MD Medicine PGY3, KIMs, Narketpally
Dr Lakshmi Vasantha, Prof Microbology, KIMs, Narketpally
Rakesh Biswas , Prof Medicine, KIMs, NarketpallyPassive participants: 1800 asynchronous online global participants consisting of MBBS and MD students, senior residents, independent researchers and faculty Professors in global locations but maximum represented from Indian subcontinent as well as Europe, US, AustraliaConversational learning outcomes:Rakesh Biswas presents the patient data that was logged and compiled into a case report by Dr Navya, Intern :
"A young man with chronic diarrhoea and severe hypoalbuminemia and generalized body swelling patient that we are currently grappling with and will appreciate your inputs
Inputs 1 from Amit Taneja
Not my area of expertise, however this is not IBD. If you have access to EGD and push enteroscopy it will be very useful to get biopsies. Clinical diagnosis is malabsorption syndrome and/or protein losing enteropathy. Cause needs to be elucidated. Work up for sprue-tropical and celiac; pancreatic insufficiency and finally obtaining biopsy. Should also screen for HIV as that will widen the ddx
RB reply
Colonoscopy pending. Rest done and dead ends.
Inputs 2 from Amit Taneja
Rakesh Biswas what did egd and small bowel follow through or push enteroscopy show? And on biopsies
RB reply 2
Upper GI endoscopy done earlier appeared normal but small bowel enema and push enteroscopy may remain pending due to affordability constraints
RB reply 3
Amit Taneja quoting from
"The three main groups of disorders that cause excess protein loss in stools are:
1) Primary Erosive/Ulcerative gastrointestinal Disorders
This group of conditions includes inflammatory bowel diseases (both ulcerative colitis and Crohn disease), Gastrointestinal malignancies, any erosions or ulcers of stomach or duodenum, Clostridium difficile colitis, carcinoid syndrome, graft vs. host disease."
Inputs from Aadipta Ghosh
Do fecal fat studies including Sudan qualitative stain for fat, 72-hour quantitative fecal fat collection, and fecal alpha-1-antitrypsin. Also go for small bowel barium series for mucosal abnormalities typical of malabsorption syndromes
RB reply
Well take a look at the jar of "paneer curry" sign in the image uploaded in his case log
AG reply
Yes then we need to rule out non erosive causes of protein losing enteropathy and primary intestinal telengiectasia. Also rule out mesenteric tuberculosis or sarcoidosis, lymphoma
RB reply
Yes Aadipta Ghosh for biopsy one does also need to spot some macroscopic findings in the endoscopy to guide the location of the biopsy. What if the findings are in the jejunum alone? How do we visualize that area?
Two days after
RB update : Upper and lower GI endoscopy apparently normal. Now what empirical Diet therapy? 😐
Amit Taneja reply: Rakesh Biswas did they do random biopsies? And if so, were they normal?
If you have a medical student or an intern, good mental exercise for them to approach it from the angle of making a table of causes of malabsorption syndromes and protein losing enteropathies. Then crossing off the ones with normal mucosa and biopsies?? And see what we are left with??
RB reply:
Yes they did and we will need to wait for the biopsy reports but it's a great idea to see what would still show normal findings microscopically
Four days later biopsy report discussion:
RB: Check out this patient's intestinal biopsy images uploaded on the patient's case log above
SK Biswas, Prof Pathology, Jinan University, Guangzhou : few blunted villi - can it be tropical sprue with superadded giardiasis?
RB reply : Yes likely.
And the organisms could be something that resembles giardia but may be named as "spruella tropicana?"
Inputs from KIMs Microbology Hod: Sir, we did not find Trophozoites in repeat sample. We found only few cysts.Above picture is showing Trophozoites. Sir, pathology report is from our Institute ?
Rakesh Biswas: Yes KHL
KIMs Micro Hod: Ok sir. After that patient took medication?
Rakesh Biswas: No we didn't give him any medication for his giardiasis till now.
He improved on a gluten free diet so I'm not yet sure if these organisms were responsible for his problem
KIMs Micro HoD: But, histopathology picture showing Trophozoites & in our microscopy ,few cysts were seen. Definitely infection is present
Kims Aditya Samitinjay: Ma'am is it feasible to treat with a 3 week course of Metronidazole for this patient ?
KIMs Microbology HOD: I have to verify treatment guidelines
Dr Faraz : Good evening sir and ma'am. Could the intraepithelial lymphocytosis and villous atrophy present be associated with celiac disease? His improvement on a gluten free diet is also another factor pointing towards that.
Kims Aditya Samitinjay: Sir he may have improved with Racecadotril and Loperamide ?
Rakesh Biswas: 👍yes thanks for these very useful inputs.
I too think as Dr Faraaz mentions that his histopathological changes can still be explained with gluten and as three interventions had been delivered to him at the same time unless and when we can remove the racecadotril and loperamide from his regime. Let's see we will hopefully do that soon
Dr Faraz : I m not convinced with the morphology as the shape & nucleus don't look like giardiasis
May b some protozoan commensals
Kims Aditya Samitinjay: Good evening ma'am. This patient's stool microscopy report on 30th August 2019 did not show any parasites or cysts, However it showed 12- 14 WBCs/hpf. This could mean his symptoms are unrelated to this Giardiasis ? And may in fact be due to Celiac Disease ?
Kims Aditya Samitinjay: Ma'am are there any features of giardiasis which could suggest chronicity ?
Rakesh Biswas: Aditya just review the literature around histopathology of chronic giardiasis
Kims Aditya Samitinjay: Partial villous atrophy, crypt hyperplasia and monocytosis of lamina propria sir.
Rakesh Biswas: Alright so essentially all these chronic changes are not specific to any particular organism and just indicate chronic mucosal damage due non specific inflammatory response
Update four days later:
RB: Have started him on Tinidazole today but here is a preemptive read to think through and ahead into the problem https://www.sciencedirect.com/
Update 10 days later
Relapsed again today after completing five days of Tinidazole by Feb 16.
2020 Ecofriendly regular asynchronous case conferences
2020:
Conference title: Patient centred clinical problem solving 2020Workshop Title: Urosepsis in presence of comorbidities and clinical complexityGuest faculty: Dr Ambarish Bhattacharya sharing his patientActive participants:Ambarish Bhattacharya -Consultant at Nightingale Hospital,Kolkata, Consultant (medicine) at Spandan Hospital and Consultant at The Apollo Clinic, Saltlake
Tarun Chakrabarti, Consultant Medicine, Apollo Gleneagles, Kolkata
Pankaj Pant, Consultant Physician, Kathmandu
Boudhayan DM, Asst professor, Medicine, AIIMS, Deoghar
Aadipta Ghosh, MBBS Student, IQ City Medical College Durgapur
Rakesh Biswas , Prof Medicine, KIMs, NarketpallyPassive participants: 1800 asynchronous online global participants consisting of MBBS and MD students, senior residents, independent researchers and faculty Professors in global locations but maximum represented from Indian subcontinent as well as Europe, US, AustraliaConversational learning outcomes:Dr Ambarish Bhattacharya presents the patient data:"70 yrs lady. T2DM, IHD, COPD, Obese with H/o # lower end of femur and hence bedridden for more than a month.Presented with off and on drowsiness and loss of appetite. Outside reports showed poor sugar control, fluctuations from Hypo to 400. Urine shows plenty of pus cells and growth of Staph. Aureus. Hb 9, TLC 16000, CRP 151, Creatinine 1.5, Na 125. Samples repeated after admission. Now culture growth Enteroccus. All others similar.Treated with Basal bolus insulin, Tolvaptan, Meropenem + Linezolid, Clexane. After 5 days CRP 45, Creatinine 0.9, TLC 12500, Na 134, Sugar well controlled. Planning for discharge.After 2 days patient has hematuria. CRP increased to 121, Creatinine 1.2, INR 2.3, aPTT > 100, Platelet 190,000, TLC 10,000, Hb 7.7. BT, CT normal. Now urine growing Candida sensitive only to Caspo & Micafungin. Caspo started, antibiotics changed to Tiecoplanin and Moxiflox, FFP given. TLC now 9500, PT, aPTT normal, Hb/Platelet/Na/K all stable but CRP now 150. Clinically other than pallor and few bedsore there is nothing. Blood cs no growth, Amylase/Lipase/RF normal, CXR normal, USG chronic cystitis.Reports of D-Dimer, FDP, ANF awaited.What should be the next line of management?Active participants inputs:
Inputs from Tarun Chakrabarti
"Discharge her with narrow spectrum oral antibiotics (according to sensitivity report) for at least 2weeks.put a catheter.Repeat urine c/s after 2weeks.
This is a case of urosepsis with metabolic encephalopathy.At this age isolated raised CRP has not much significance.Instead can do PCT.What is LFT report?why ANF,RF,amylase,lipase done?"
AB reply
Tarun Chakrabarti Only low Albumin. All others normal.
Even Procal normal.
Inputs from Pankaj Pant:
Any underlying conditions like multiple myeloma
AB reply
Pankaj Pant Pending reports: ANF, D-Dimer, FDP, Protien electrophoresis
Input from Boudhayan DM:
What is ESR ?
AB reply
Boudhayan Dm 80. But Hb is 7. Microcytic hypochromic
Input from Rakesh Biswas
Interesting urine culture fluctuations. First staph then enterococci then fungi. What was the enterococcus susceptible to?
Sanchita Das, Biswaroop Chatterjee, Dipmala Das, would you like to comment
AB reply
Rakesh Biswas More problematic is the sudden rise in CRP with rise in INR and aPTT along with fall in Hb, Tc, Dc and Albumin. And Hematuria. But Bilirubin, ESR, Platelets remains same. No rash or arthralgia. All lines changed. Daily UB wash with saline. New sets of Blood cs, Urine cs, stool cs sent. Reports of C. Diff toxin, ANF, Protein eletrophoresis, FDP, D Dimer still awaited
RB reply below
I guess as long as the WBC counts and clinical symptoms are holding well we can breathe easy? Will be keen to see how the current abnormal markers evolve.
Input from Aadipta Ghosh
You can do a lipid profile. CRP rises with increased LDL. Rule out underlying malignancies, inflammatory bowel disease and do an autoimmune panel.
RB reply
Please share links to the utility of lipid profile in correlation with CRP
RB reply after Aadipta shares links :
Thanks Aadipta. Can you quote the relevant portions that suggest that it helps in further management.
Aadipta reply:
Quote "In conclusion, our data show that Ox-LDL and hs-CRP levels correlate positively in ACS patients, supporting the hypothesis that Ox-LDL and CRP may play a direct role in promoting the inflammatory component of atherosclerosis in these individuals. We suggest that Ox-LDL/CRP elevated levels may serve as markers of the severity of the disease in evaluation and management of ACS patients."
RB reply:
They suggest they could be markers but that's a long way away from being useful in such a case scenario?
Two days later inputs from Pankaj Pant
Any updates or diagnosis?
AB reply Pankaj Pant Pyelonephritis
Update two more days later by AB
TLC came down from 17500 to 13400 but now again increased to 15200.
CRP down from 235 to 144, but BP dropping. Needs Norad but urine output holding. No growth in any cultures
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