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

About Me

caregiver7careseeker

View my complete profile

Powered by Blogger.