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.