Sunday, December 5, 2021

December 2021 weekly log and outcomes of regular patient centered learning sessions

This is a regular academic session impact assessment log for the post graduate residency training program comprising currently of residents of 2019 and 2020 batch. 

The training program comprises of a regular hands on learning of clinical decision making during the bedside rounds from 10 AM to 1:00 PM as well as 2-4 sessions officially divided daily into:

Theory on Monday, 

Seminar on Tuesday, 

Journal club on Wednesday, 

Tutorial on Thursday 

Group discussion on Friday 

Log Book audit on Saturday 

These are blended learning sessions with both online and offline components and while the offline learning timings are as mentioned above, the online component of the learning continues 24x7.

The overall impact of each learning session is assessed under two main headings as impact on the student and impact on patient. 

The detailed headings are :


Impact : 

On learning ecosystem :

Cognitive competency levels touched in different levels of Blooms taxonomy BT (more here : https://sites.pitt.edu/~super1/lecture/lec54091/002.htm):

Approach to disease localization (BT level 1 -3)

Resolving initial diagnostic uncertainty (BT level 1-4)

Therapeutic decision making toward evaluating patient requirements and outcome (BT level 1-5)

Developing and testing innovative diagnostic and therapeutic solutions ( BT level 1-6)

On patient care outcomes :

Was empathic trust built with patient and relatives?

Were the patient requirements identified adequately and a proper problem list made toward assessment? 

Was standard of care provided with provision for care continuity ?
Prepared below from first week of December by Rashmita PGY3

December 1st Wednesday : 

journal club :

"Sun et al.13 performed a prospective study (level 2b evidence) on a cohort of 108 patients, in which 26 patients were treated with DX alone, 69 underwent burr-hole craniotomy and adjuvant corticosteroids, and 13 were treated with surgical drainage alone. In the corticosteroid group, 1 patient required surgical drainage, whereas in the surgical group hematoma recurrence was reported in 3 patients; no significant difference between the two groups was measured."


Dr Usha 
Dr Rashmitha 
Dr Durga krishna

And UGs 

2nd December Thursday Tutorial :
Video :


Facial Nerve UMN LMN

Presented Dr Rashmitha
Attended by Dr Durga krishna Dr Usha and UGs 

3/12/2021 Friday 

Group discussion

Heart failure 


4/12/2021

Saturday 

Log Book assessment 

Presentation of thesis logs by PGY3s just before getting their final signatures. 

*Date : 06/12/21. Monday* ( Theory class)

Alcohol, comorbidities and multiorgan failure 


Attended by Dr Dk 
Dr Rashmitha
Dr Usha and 2018 UGs 

7/12/2021 Tuesday seminar

COPD presentation by Dr surya internee


Attended by Dr Rashmitha 
Dr Dk
Dr Usha and 2016 interns 

Integrated seminar with Pulmology and Psychiatry 

Around a patient with suspected drug interaction causing Giddiness

Attended by Dr Divya 
Dr usha
Dr DK
Dr Rashmitha and Psychiatry and Pulmonology PGs and Faculty. 


Date 8/12/1/21

Wednesday Journal club


Use of thyroglobulin as a tumor marker 

Context : current admitted patient of thyroid carcinoma with humerus fracture who recently received radioactive Iodine 131. Case report link here :https://decodemed.blogspot.com/2021/09/this-is-online-e-logbook-to-discuss-our_12.html

 
 9/12/2021

Thursday Tutorial 

Management of hypercapnia and the role of volume control vs pressure control 

Context :


Rs b/l decreased breath sounds+
P/a soft, non tender
Grbs 101 mg/dl
I/o 800/1000

pH -7.35----7.38----7.41----7.38
Pco2-131--110----117-----137
Po2---340---68.6--62.1---83.6
Hco3--70.5--64.4--74---80.2
St.hco3--61.9--56--66.2--72.3
O2 sat--99.4---92--90---95.2

A- Corpulmonale with type 3 pulmonary arterial hypertension 
Severe respiratory acidosis
bronchial asthma
Denovo diabetes 

10/12/2021

Friday Group discussion 


Etiology of renal failure 

Patient context : 

Discussion on ACEI vs Hydralazine:

To define better the efficacy of vasodilator therapy in the treatment of chronic congestive heart failure, we compared the effects of hydralazine and isosorbide dinitrate with those of enalapril

References used :


11/12/2021

Saturday log book evaluation :

Log books evaluated for 

Dr Rashmita and Dr Divya 

Observations :

No log of answers to the online assignments from June 2021 to November 2021!

The May 2021 answer was read out and many inadequacies were found the learning points of which will be summarized by the evaluated PGs. 

The PGY3s were also asked if they would prefer to have a timed hand written question paper for them to answer followed by their uploading their hand written answers toward global peer review feedback (as well as allow them to practice writing theory answer papers as is the current norm for their final university assessments) and there has been no positive response to this option as well till now. 

It was observed that very few PGs had shared their thesis work logs in the manner below (although instructed to do so since the beginning of their thesis) as illustrated here : 

12th December, Sunday 



Date 13/12/21 ,Monday - 10-11 AM class 

Case presentation by thanmayee

2-4 pm Theory


Discussed about Benign heriditary chorea

"BHC is caused by mutations in the NKX2-1 gene (also known as the TITF1 gene). It is passed through families in an autosomal dominant fashion."


Attended by Dr Dk pgy2
Dr Rashmitha pgy3
Dr Usha pgy3


*Date 14/12/21, Tuesday*

11- 1class: 
Case presentation by Shivani 3rd year MBBS student.

Case presentation by Final year mbbs student in 11-1 Class
 
2-4 pm class Seminar 

Dosage titration of tetrabenazine plasma concentration


The starting dose should be 12.5 mg/day once in the morning. After one week, the dose should be increased to 12.5 mg twice daily; it should then be titrated up slowly by 12.5 mg at weekly intervals to identify the lowest and best tolerated effective dose. If a dose of 37.5 to 50 mg/day is needed, it should be given in three divided doses. Each dose should not exceed 25 mg. Patients who seem to require doses greater than 50 mg/day should undergo genotyping for CYP 2D6. Doses above 100 mg/day are not recommended for any patient.

Attended by Dr Dk pgy2
Dr Rashmitha pgy3
Dr Usha pgy3


*Date 15/12/21, Wednesday- Journal club* 

Case presentation by final year MBBS student.

 *Elog link:* 


2-4pm journal club

Hypopituitary Females Have a High Incidence of Cardiovascular Morbidity and an Increased Prevalence of Cardiovascular Risk Factors



Attended by Dr DK pgy1
Dr Rashmitha pgy3
Dr usha pgy3


*Date 16/12/21, Thursday

Case presentation by final year MBBS student.


 *Elog link :*

2-4 pm class Tutorial (ITP)
Mechanism of Action of Tetrabenazine

Currently we are giving her only tetrabenazine ,which is a VMAT (vesicle mono amine transport inhibitor) ,i.e it prevents dopamine release. For this she isnt getting symptomatic relief . So we can add additionally D2 (dopamine receptor blockers) ,like atypical antipsychotics( olanzepine,risperidone etc) .Can reduce the frequency of attacks and also
 might  help with the psychiatric issues she is facing .


Attended by Dr DK pgy1
Dr Rashmitha pgy3
Dr Usha pgy3

*Date 17/12/21, Friday -* 2-4 pm , Group discussion.

Differential Diagnosis of chronic vomitings and Diagnostic modalities available for chronic pancreatitis.

Case presentation by Intern 



Elog link: 


Attended by Dr DK pgy1
Dr Rashmitha pgy3
Dr sushmitha pgy3






Date : 20/12/21 , Monday - Theory* 

Case presentation by final year MBBS student .



 *Elog link :* 


Attended by Dr Durga krishna pgy2 
Dr Rashmitha pgy3
Dr sushmitga pgy3

2-4 pm Theory
36 year old female with Unicornuate uterus with ?Ovarial failure 
Discussed about utility of MRI in diagnosing the Unicornuate uterus vs Cornual block

Attended by Dr Durga krishna pgy2 
Dr Rashmitha pgy3
Dr sushmitha pgy3

 *Date 21/12/21, Tuesday - Seminar*


 *Elog link* : 


2-4 pm Seminar
40 year old female with cirrhosis of liver secondary to NAFLD, metabolic syndrome
Pathophysiology of metabolic synrome causing NAFLD cirrhosis of liver, portal hypertension.



“The diagnostic performance of MR elastography in liver fibrosis staging was similarly high in the groups with and without CHB, but the cutoff LS values for diagnosing liver cirrhosis differed between the groups with and without CHB.”


Presented by Dr Moulika internee
Attended by Dr Durga krishna pgy2 
Dr Rashmitha pgy3
Dr sushmithapgy3

 *Date 22/12/21, Wednesday,- Journal club* 


 *Elog link:* 


Attended by Dr DK pgy2
Dr Rashmitha pgy3
Dr sushmitha pgy3

Date 23/12/21, Thursday, - Internship training program for interns - Tutorial 

Presenters : 
1) Moulika
2) Huda

 *Presentation videos*: 



Elog link : 

Questions raised
Causes of post dialysis infections Infections 
Pathophysiology of NSAID induced Renal failure


There are not many studies yet showing the long-term effects of NSAIDs on the development of chronic kidney disease (CKD). However, it has been shown that daily use for more than one year increases the risk of developing CKD.14

There may be progression in patients who do not discontinue NSAIDs when they develop acute interstitial nephritis and interstitial fibrosis.5"


Attended by 2016 interness
Dr DK pgy2
Dr rashmitha pgy3
Dr Sushmitha pgy3


24/12/2021 Friday Group discussion

2-4pm class
Why does recurrent hypoglycemia in liver mets


Some patients present with hypoglycemia and liver metastases; among them, only a few develop hypoglycemia as a result of a failure of hepatic glucose production. Most develop hypoglycemia as a result of an insulin-mediated process--either the secretion of insulin by an islet-cell tumor or the secretion of insulin-like growth factor-II by an extrapancreatic tumor.


Three patients had an insulinoma and four had non-islet cell tumor hypoglycemia (NICTH) due to hepatocellular carcinoma, colon carcinoma, meningeal sarcoma, and hemangiopericytoma, respectively. All of the patients had liver metastases

Glucagon stimulation test (serial glucose measurements after a 1 mg infusion of glucagon) as part of the workup for hypoglycemia were retrospectively reviewed. Those patients whose test revealed a rise in serum glucose of >30 mg/ dL were subsequently treated as outpatients, with a continuous glucagon infusion delivered by a portable pump.

Why does recurrent hypoglycemia occurs in patient with Liver mets
1. All patients with insulinoma responded to glucagon with a rise in blood serum glucose levels, indicating adequate glycogen stores.
2. The four patients with NICTH had mixed responses: in two patients, the response suggested that hypoglycemia was due to an insulin-like tumor product; 
3.glucose levels did not rise in the other two cases, indicating that hypoglycemia was due to poor hepatic glycogen reserve/liver failure. 
In all cases, a glycemic response to glucagon predicted good response to long term treatment with glucagon (0.06-0.3 mg/hour, via intravenous infusion pump).


Dr DK pgy2
Dr rashmitha pgy3
Dr Sushmitha pgy3
27/2/2021 Monday seminar
 2-4 pm class 
Treatment options for CBD stricture



Attended by Dr Dk pgy1
Dr sushmiths pgy3
Dr Rashmitha pgy3

28/12/2021 Tuesday Theory class

2-4 pm class 
Nephrotic syndrome 




Attended by Dr Dk pgy1
Dr sushmiths pgy3
Dr Rashmitha pgy3


29/12/2021 Journal club

Dr Huda : case presentation about Dialysis Dysequilibrium syndrome 



Attended by Dr Dk pgy1
Dr sushmiths pgy3
Dr Rashmitha pgy3

30/12/2021 Tutorial

Case discussed on Mitral stenosis and murmurs 

Attended by 
Dr Dk pgy2
Dr Rashmitha pgy3
Dr k vaishnavi pgy3
Dr sushmitha pgy3
Dr Nikitha pgy3




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Formative (internal) assessment criteria for guaging students impact on a patient centered learning ecosystem

Introduction background (and problem statement) : 


Formal healthcare education systems in Indian Medical education curriculum, tailor their assessments into two groups namely theory and practical. 

Although currently, "theory" appears to be an assessment framework based on "student conceptualizations," it's design has evolved in many universities to allow students to simply memorize factual content and crack it by copy pasting the same in their answers (reference : all university data bases archiving student answer papers and the one linked here may be an outlier: https://medicinedepartment.blogspot.com/2021/11/selected-answers-to-2017-internal.html?m=0). 

Practical and viva exams (interviews), on the other hand are meant to test a student's ability to capture and analyze patient data toward clinical decision making along with demonstrable procedural competencies. While much has been written around summative practical assessments (reference : https://medicinedepartment.blogspot.com/2021/03/final-university-mbbs-medicine.html?m=0), very little exists around how formative practice assessments have to be conducted in our local learning ecosystems (problem statement).

Although, many review articles exist, developed by local eminent educationists and policy makers (reference : https://www.ijabmr.org/article.asp?issn=2229-516X;year=2021;volume=11;issue=4;spage=206;epage=213;aulast=Saiyad;type=3) around overall assessment they are largely focused on summative quantitative assessment rather than formative qualitative assessment and to quote from the same article, "quantitative measurements provide the idea about the overall achievement of the students but give no idea about the factors affecting the performance often resembling a cross-sectional study, which didnot allow the teachers and students to learn contextually (due to lack of longitudinal information continuity)."

Method :

Getting back to how our current theory papers are structured in Indian Medical education system, it can at best claim to address the first level of Blooms taxonomy that is remembering and understanding (A candid lecture on blooms taxonomy here : https://sites.pitt.edu/~super1/lecture/lec54091/002.htm). Also, most colleges find it easier to administer repeated monthly theory assessment papers that they call FA1, FA2, FA3 FAn etc (where FA stands for formative assessment) and in some colleges this is internal assessment so it becomes IA1, IA2, IA3, IAn etc. 
 
We would have preferred not to mix qualitative formative assessments with quantitative summative assessments but due to the majority usage of this mixed method model (which is in reality a more frequently repeated quantitative summative assessment model masquarading as formative),  we too are compelled to develop and share our method of a compromise where we try to accommodate the summative theory paper quantitation as a springboard to begin their assessment process with their prowess in tackling the first level of blooms taxonomy. 

So the theory quantitation of 60 marks is divided into scores of 

10-20 

20-30

30-40

40-50

if a candidate achieves 

10-20 s/he would in the conventional summative be declared a failure but because our formative, internal assessment is not assessment OF learning but assessment FOR learning, we try to find out if the same person has made an impact on our learning ecosystem in other ways with her inputs in the wards around her patient that reflects his her's :

Approach to disease localization (BT level 1 -3)

enthusiasm to resolving initial diagnostic uncertainty (BT level 1-4)

toward therapeutic decision making and tenacity to evaluating patient requirements and outcome (BT level 1-5)

Developing and testing innovative diagnostic and therapeutic solutions ( BT level 1-6)

On patient care outcomes :

Was empathic trust built with patient and relatives?

Were the patient requirements identified adequately and a proper problem list made toward assessment? 

Was standard of care provided with provision for care continuity ?

So once we have the theory quantitation of each candidate's answer paper and find that a candidate securing 10-20 out of 60 hasn't been able to also participate in the patient centered practical learning ecosystem and is unable to touch upon any of the above listed impact criteria we may flag the student in the red zone of 10-20 and monitor his her progress closely to improve his her competence to a higher zone. 

20-30 would be still an orange zone outlier 

30--40 would be average and more than that would be a positive outlier  

Results :

So the internal/formative assessment results could be displayed in a mixed method manner with a quantitative-qualitative zone that is numbered and color coded. 

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Monday, November 22, 2021

Rough draft of internal assessment 2017 batch September 2021 performance

 DEPARTMENT OF GENERAL MEDICINE 

8TH SEM 1ST INTERNAL MARKS – SEPTEMBER - 2021




The students who achieved marks toward higher end of the spectrum demonstrated reasonable competency with regard to scholarship (theory summative answers and formative log book) as well as leadership (pro activity in making an impact on our patient care workflow by their useful inputs both synchronously recorded in their presentation videos as well as asynchronously in their texted inputs recorded in their E logs.  

Possible explanations for those who received low marks  are :

Didn't attempt all questions in theory paper 

Inspite of attempting didn't demonstrate substantial scholarship competency in the topic. 

In day to day assessment were unable to share their daily learnings with peers, were largely uncommunicative and overall provided poor demonstration of scholarship and leadership competency necessary for practice of medicine. Hopefully they will improve after this feedback. 

R. No.

Name

Max Marks

(60)

1



2





66


20



108


20



144


20




147


20



172


20



174


20



176


20



181


20



186


20


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Project : Outcomes of bicarbonate correction in severe high anion metabolic acidosis due to renal failure along with one case report form and CDSS

Project introduction :


"Replacement of sodium bicarbonate to patients with sodium bicarbonate loss due to diarrhea or renal proximal tubular acidosis is useful, but there is no definite evidence that sodium bicarbonate administration to patients with acute metabolic acidosis, including diabetic ketoacidosis, lactic acidosis, septic shock, intraoperative metabolic acidosis, or cardiac arrest, is beneficial regarding clinical outcomes or mortality rate. Patients with advanced chronic kidney disease usually show metabolic acidosis due to increased unmeasured anions and hyperchloremia. It has been suggested that metabolic acidosis might have a negative impact on progression of kidney dysfunction and that sodium bicarbonate administration might attenuate this effect, but further evaluation is required to validate such a renoprotective strategy."

Above quoted from :


Case report form for one patient :


Conversational learning around the same patient :

[11/21, 7:42 PM] Moderator : 

Log Book assessment: PG Med  


Context : An elderly patient with severe anemia, hypotension, severe metabolic acidosis, encephalopathy and recent fracture femur 

More :


Impact : 


On learning ecosystem :


Cognitive competency levels touched :


Approach to clinical localization of disease pathology was done reasonably well and differential diagnostic hypothesis formulated 


On patient care outcomes :


Empathic trust built with patient and relatives 


Standard of care provided with provision for care continuity  


Challenges met/not met : managing diagnostic  arranging of repeating hemoglobin levels, repeat imaging to assess hematoma, continuing dialysis, reviewing the literature around giving bicarbonate in high anion gap metabolic acidosis 


[11/21, 7:43 PM] Moderator : 👆How is this patient now? 🤔


[11/21, 7:44 PM] PG Med: Sir he expired at 10 am today ,



[11/21, 7:44 PM]  PG Med: 

Quoting from above link :

Dialysate (HCO3–) prescriptions differ widely throughout the world. About half of HD patients in the United States are dialyzed in ≥37 mEq/L dialysate (HCO3–) [34], while 83% of HD patients in Japan are dialyzed with dialysate (HCO3–) of <30 mEq/L [35]. Metabolic alkalosis due to the high dialysate (HCO3–) has been associated with the occurrence of cardiac arrhythmia, intradialytic hypocalcemia, hypokalemia, hypercapnia, hypoxia, intradialytic hypotension, and vascular calcification [36, 37]. In patients with chronic obstructive pulmonary disease (COPD) or other causes of ventilator impairment, higher dialysate (HCO3–) can cause CO2 accumulation and potentiate hypoxia. The DOPPS report also demonstrated a dramatic increase in mortality due to severe infection in patients receiving higher (HCO3–) dialysate [34]. Increasing dialysate (HCO3–; in the range of 28 and 40 mEq/L) induces intra-dialytic and post-dialysis alkalosis but has no effect on pre-dialysis acidosis [38, 39]. To prevent pre-dialysis acidosis, oral NaHCO3 may thus be considered.





[11/21, 7:45 PM] PG Med: The bicarb correction had also caused respiratory acidosis sir


[11/21, 7:46 PM] PG Med: His sensorium also deteriorated and when we wanted to intubate, he went into cardiac arrest

[11/21, 7:49 PM] Moderator : So what was the dialysate prescription that had been given to our patient on Day 1? 

Interestingly his hypotension too was intradialytic and he had come with a normal BP on admission?

[11/21, 7:52 PM] PG Med: Yes sir presentation bp was 150/90mmhg, first intradialytic bp drop required single ionotropes for 6 hours post dialysis


[11/21, 7:52 PM] Moderator : Share his first dialysate prescription

[11/21, 7:58 PM] PG Med: Yesterday he had an episode of bradycardia in the afternoon when his pco2 wasn't raised sir,revived with atropine , so I think bradycardia is a seperate episode sir

[11/21, 8:00 PM] PG Med: Sir casesheet is dispatched
Intradialysis first day for 2hour dialysis 200 meq was given in the can sir,the rate of delivery is variable per hour, so around 75 to 50 meq was given 
Second day 300meq in 4 hours , which was again 50 to 75 new/hour sir


[11/21, 8:03 PM] Moderator : How do our dialysate bicarbonate concentrations compare with the ones shared in the above linked paper


[11/21, 8:04 PM] Moderator : Did our high dialysate concentration induce metabolic alkalosis? 

Also do our dialysis doctors vary the dialysate concentration in a case by case basis?


[11/21, 8:08 PM] PG Med: Vary case by case sir

[11/21, 8:08 PM] PG Med: We undercorrect it sir, only half of the requirement is given to prevent metabolic alkalosis


[11/21, 8:09 PM] PG Med: But for him as acidosis was refractory, contemplating whether we overcorrected it

[11/21, 8:11 PM] Moderator : So how do we decide how much to give?


[11/21, 8:12 PM] Moderator : His terminal acidosis was respiratory?


[11/21, 8:12 PM] PG Med: We calculate the deficit sir
And give half of it in the can and not directly if the patient can wait till dialysis,
Rate of delivery per hour ,I did not check sir
If he's having symptoms of overload we simultaneously remove more ultrafiltrate sir


[11/21, 8:12 PM] PG Med: Yes sir breaths became shallow


[11/21, 8:13 PM] Moderator : Could his respiratory depression have been due to metabolic acidosis which precipitated respiratory acidosis terminally?


[11/21, 8:15 PM] PG Med: Been trying to find that mechanism sir, the extra co2 did it come from the bicarb or did hypoventilation cause it


[11/21, 8:16 PM] Moderator : Hmm generally when we see extra Pco2 we always think respiratory while if we would have thought extra bicarb that would be reflected as metabolic alkalosis? 🤔


[11/21, 8:18 PM] PG Med: Yes sir but if his respiratory centre is compromised will alkalosis happen


[11/21, 8:18 PM] Moderator : Did he have alkalosis or acidosis?


[11/21, 8:19 PM] PG Med: Respiratory acidosis sir

[11/21, 8:19 PM] Moderator : So why think about alkalosis?

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Project "resolving diagnostic uncertainty in fever" Case report form link and Patient centered conversational learning

Past projects around the above context in the links below :


UG student thesis 2003:

UG student thesis 2005:


PG student thesis : 2012-13

Review of literature links for the above thesis :


Current project link :


Current case report form link and beginning of November 19, 2021 discussion link below :


Conversational decision support system CDSS for the above case copied below :


[11/21, 9:22 AM] : intern notes 


39M AMC BED 1

S


- Continuous fever spikes present above 102 F associated with chills 
C/o burning micturation subsides and increased frequency of urination,low backache increased on bending forward

O- TEMP-101F
Bp-110/70mmhg
Pr-90bpm
Cvs-s1,s2heard
Rs- NVBS
CNS-NAD

A


- Diagnosis is ? Acute pyelonephritis and urge incontinence .
Dm-2 
?clinical malaria

Urine c/s - no growth 
Sent repeat blood and urine c/s
Smear for mp - negative.
Repeat cue - no RBC casts and pus cells -8-10 .
Xray kub was done in view of ??emphysematous pyelonephritis .


P

1.Tab.CIPROFLOXACIN 500 MG /BD
2.Tab.PAN 40MG OD
3.TAB.PCM 650mg QID
4.Tab.AMLONG 5mg PO OD
5.Tab.URISPAS PO BD
6.INJ.HUMAN INSULIN
7.Syp.CITRALKA 10ML IN ONE GLASS WATER POBD
8.GRBS MONITORING
9.INJ.FALCIGO 120MG IV STAT
10.BP/PR/TEMP MONITORING

[11/21, 9:22 AM] moderator : USG abdomen revealed any perinephric abscess?

[11/21, 9:22 AM] PG Med: No sir it did not reveal any abscess, there is no loin tenderness on palpation

[11/21, 9:22 AM] :  moderator
Start him on iv Meropenem today asap

11/21, 9:22 AM] PG Med: Ok sir

[11/21, 9:23 AM] Moderator : Share his blood sugar trends since admission


[11/21, 7:02 PM] Moderator : Why did we add falcigo when the localization was pointing towards UTI? 🤔

[11/21, 7:17 PM] PG Med: Sir because of the spike every 12 hours ,

[11/21, 7:19 PM] Moderator : Why didn't we think it was UTI

[11/21, 7:21 PM]  PG Med: Yes sir his fever had chills each episode,true for uti, 
We thought of malaria as well sir , inspite of antibiotics frequency or temp didn't come down

[11/21, 7:21 PM] Moderator : So purely from our medical cognition research insight perspective one can conclude that in the face of diagnostic uncertainty that keeps continuously giving irritating alarms, doctors often tend to cover all the differential diagnostic possibilities and reduce the chances of their future regret?

[11/21, 7:39 PM] PG Med: Sir may I ask, why did we choose meropenem for this patient?

[11/21, 7:40 PM] moderator : 

The answer is here 👉([11/21, 7:02 PM] Moderator : Why did we add falcigo when the localization was pointing towards UTI? 🤔)

I didn't even notice that he had been started on empirical falcigo from yesterday evening

Meropenem was the antibiotic escalation for the strong differential of UTI in the moderator's mind although rest of the team thought falcigo was good enough. 

Medical cognition Inferential queries:

Could we have held back on antibiotic escalation if the PG Med had voiced her query regarding meropenem earlier instead of immediately agreeing to switch over? 

What really helped the patient? Falcigo or meropenem?   




 
PG Med Yes he has a spike of 102 now

11/22, 7:37 PM] Moderator : Subjectively?


[11/22, 7:39 PM] PG Med: At the time of spike ,he is having chills sir ,but not as disabling as the rest of the times as per him, 
Rest of the time he's comparatively more active


[11/22, 7:39 PM] moderator : This sounds like malaria 🤔😬


[11/22, 7:40 PM] moderator : Are we still continuing the Artemesin?


[11/22, 7:40 PM] PG Med: Yes sir , but he already has taken 3 doses of falcigo so far


[11/22, 7:40 PM] PG Med: The 48th hour dose is due tomorrow morning at 8 sir


[11/22, 7:40 PM] Moderator : What is the continuation strategy for falcigo in toto?


[11/22, 7:42 PM]  PG Med: Should have voiced about giving falcigo and notified the initial dip so that meropenem wouldn't have been started sir, 
His loin pain is more musculoskeletal than pyelonephritis as he's having it on bending .


[11/22, 7:47 PM] PG Med: 2.4mg/kg at 0,12,24 and 48 hrs sir


[11/22, 7:49 PM] Moderator : Hmm that would have saved some meropenem. 
How about reviewing the repeat urine culture and if negative for a second time we can stop meropenem?


[11/22, 8:09 PM] Moderator : Yesterday in the 2016 group someone said the urine routine was showing 8-10 pus cells although the prior RBCs had receded. What could be the reason for that? He also gave a history of hematuria with his loin pain in the initial phases?


[11/22, 8:43 PM] PG Med: Sir the transient haematuria can be due to uti itself, due to inflammation, his symptoms of burning micturition subsided when the repeat cue (complete urinary examination) came back negative for rbc as well


[11/22, 8:47 PM] Moderator : But he had 8-10 pus cells. 

How many pus cells did he have when he had 3-4 RBCs?


[11/22, 10:21 PM] PG Med: On the day of admission he had 3-4 pus cells with 3-4 rbc's
Repeated cue on Saturday has 8 to 10 pus cells ,with 1-2 rbc sir

November 19, 2021

Friday 

Group discussion: 

Context : PUO in a male diabetic with loin pain and lower urinary tract symptoms of urgency and burning 


Presenters : Dr Vaishnavi, Dr Nikita, Dr Pooja (intern) and Dr (Soujanya 2017)


Impact : 

On learning ecosystem :

Cognitive competency levels touched :

Approach to clinical localization of disease pathology was done reasonably well and differential diagnostic hypothesis formulated in the face of high diagnostic and therapeutic uncertainty 

On patient care outcomes :

Empathic trust built with patient and relatives 

Standard of care provided with provision for care continuity  

Challenges met/not met : 

Fever monitoring and post admission illness timeline was well supervised. 

Imaging and labs for further  clinical localization of the PUO was driven by the discussion 

Multiple therapeutic interventions were made for the differentials in the face of diagnostic uncertainty further driven by ongoing patient suffering and an attempt to gather the "medical cognition" learning points made here : 

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