Tuesday, April 13, 2021

Medicine paper for April 2021 bimonthly blended assessment

 13/04/2021 11:00 AM 


Answer all questions:                                                      

Max Marks: 100 (5 questions in total and 20 marks for each  answer) 

Submit by:   25/4/2021               


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-assessment-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 plan and context:

We are also utilizing this online assessment platform for a participatory action research strategy in "Scholarship of integration in Medical education research" as part of a commissioned book project and your online answers will also be analyzed and interpreted with that intent. 

A brief word about the book project outline before we move into the stem of the question paper: Scholarship of integration in medical education and research aims to disseminate back to society the fruits of academic discovery and translates medical education theory that developed from discoveries made by individual academics in countless individual members of society into a practice that again benefits the same or different individual members of society. For more click on: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1891293/

The questions below cover the entire spectrum from medical humanities, anatomy, physiology to diagnostic, therapeutic uncertainty and computational tools popularly known as ML AI to resolve one disease theme and predictably move from symptoms to diagnosis and treatment challenges. 

Most questions test the reading comprehension skills of the examinee and some prior familiarity with medical terms and strategies and also more importantly assesses their ability to use online search tools toward better expression of their learning points in the form of answers that are again made available open access for post publication peer review.

In summary the answers to the following questions in this online question paper will assess the examinee's competencies in dealing with:

Clinical problem solving 

Medical terminologies familiarity including areas of anatomy, physiology, pathology, ML, AI 

Empathy and medical humanities 

Current EBM strategies for managing diagnostic and therapeutic uncertainty 

Section 1) Please go through the patient data in the links below and answer the following questions:


Anatomic and physiologic localization of symptomatology 

In patient's own voice:

Patient 1

"I suffered from bad cramps and loose stool movements – and not the usual stomach cramps, it felt like someone was trying to tear out my insides.

On top of that, I was constantly bloated, suffered from bad mouth ulcers, mood swings, hot and cold chills, weight loss, and the dreaded haemorrhoids. It was only in the last year that I started noticing a lot of blood in my stools (lovely I know). My whole body was in pain, from my joints to my muscles, and to my mental state. This led to me becoming quite depressed and anxious, making matters a whole lot worse."

Patient 2:

"I had just gotten back from a holiday with a group of my friends when I had to leave work. I was experiencing constant fever symptoms, I fainted a few times and I was going to the toilet about 15-20 times a day. Not only this but every time I had to use the toilet I was losing blood"

Quoted above from: www.irishtimes.com/life-and-style/health-family/my-daily-routine-living-with-inflammatory-bowel-disease-1.3368509?mode=amp

Patient 3

"2004 and early 2005 were the the darkest days of my life. With no proper diagnosis and treatment, I was going nowhere. Every day was a challenge. I cloud barely drink a glass of fruit juice. No question of taking solid food. Just a bit of solid food in my mouth, it used to cause intense burning. If I managed to forcefully swallow some food, I used to vomit immediately. I was weighing 30kg, just skin and bones. Everyone lost hope, I was not knowing what went wrong and on top of that, everyone who came to see me used to say " your parents and doctors are putting all the efforts to make you healthy, but you don't seem to put any kind of effort or show any intension to get better. Looks like you are enjoying being sick and you want to remain sick.

They were giving me all kinds of suggestions ' why don't you eat, why don't you get up from the bed etc etc. I felt inside ' if these people, even for a minute, go through, the kind of pain I'm bearing for years and, manage to live for a couple of days, I would listen to their suggestion.

Suicidal thoughts were coming, I decided to end my life, luckily my mother came to my rescue and told me ' if you want to die, you should not die alone, I will also end my life along with you ' she said live and fight. That day I promised her, come what way, I'm not going to give up."

Above quoted from: https://medicinedepartment.blogspot.com/2021/04/empathic-narrative-in-inflammatory.html?m=1

In health professional's notes:

Patient 4:

"35/ M who works as a  mason presented to us with history of 

1) bleeding per rectum -3-4 episodes / day for 2-3 days , associated with hard stools +
Intermittently - for 5-6 months and he Was said to have anal fissure ,used sitz bath and ointment .
No altered bowel habits at that time .

Since December 2020- Patient complaining of - altered bowel habits ,for 10 days he passes  stools with normal  consistency and frequency then followed by hard stools for 2 days then followed by loose stools -small quantity ,associted with mucus + and blood , foul smelling stools ,2-3 episodes per day ,tenesmus + .no difficulty in flushing stools ,Relieves with fasting .These last  for one week , subsides with sitz bath and lignocaine topical application .
Then recurrs again after 10-15 days .

February 2021 - patient had 3 eipsodes of loose stools with severe pain abdomen-left iliac region ,non radiating , he was taken to local hospital ,
Usg - pancreatitis ,Gastritis .
Patient lost 5kgs   in 6 months .
No fever ,no joint pains ,no vomitings ,no fresh bleed .
Since 5 days before presenting in April 2021, Patient complaints of loose stools -small quantity , tenesmus + ,with mucus and blood .no pain abdomen"


Question 1) What are the common themes emerging from these symptom narratives? Does the symptomatology related by the patient's own voice evoke more empathy than the one in the health professional notes? Are there studies correlating patient empathy generated in health professionals to disease outcomes or even the doctor patient relationship? 

Question 2) One easily appreciable theme in all these narratives is the impact of the colonic pathology on the patient's psyche with severe symtomatologies precipitating suicidal depression. While the influence of somatic pathology on psyche is easy to appreciate are their studies demonstrating the influence of psyche and life events (that are often part of symptomatology narratives) on disease pathology manifesting in the soma? Please go through the article linked here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1774724/ and list the evidence for the fact that both chronic stress, in the form of adverse life events, and acute experimental stress can affect systemic immune and inflammatory function, and increase disease activity in humans with IBD.

Diagnostic and therapeutic uncertainties 

Diagnostic uncertainty:

Patient 3:

"I spent first 10 years of my life absolutely healthy. Started becoming sick after that. Saw few local doctors both allopathy/homeopathy, they said everything was fine, but I wasn't improving. Later met one of the leading gastroenterologist at ABCD Institute of Gastroenterology who diagnosed me as having TB in March 2001 and put on Anti Tuberculosis Treatment for 3 years that ended in march 2004.

After 3 years of pain and suffering, I went from bad to worse. The doctor said ' why did you come again, your treatment is over'.  I asked doctor the reason for not recovering he said ' it might not be TB, it might be some other disease, get admitted we will evaluate again'.

I could not digest those words, I was seeing him every fifteen days for 3 years with all the tests and reports.

2004 and early 2005 were the the darkest days of my life. With no proper diagnosis and treatment, I was going nowhere. Every day was a challenge."

Above quoted from:

https://medicinedepartment.blogspot.com/2021/04/empathic-narrative-in-inflammatory.html?m=1

Patient 4:

In this patient logged by our Intern here  http://sruthi995.blogspot.com/2021/04/is-online-e-log-book-to-discuss-our.html there was a debate among the health professional team managing him around what if they were missing a tuberculosis of the colon? What if the previous colonoscopy and biopsy had missed the diagnosis of tuberculosis especially as it hadn't been done by a Gastroenterologist but by a general surgeon? While a repeat colonoscopy and biopsy was planned again the expenses were too much to bear for the family members who left after promising to try getting the colonoscopy at a cheaper price from elsewhere and return to us for follow up. 

Therapeutic uncertainty:

Patient 1:

"I was taking several different medications at a time for over four months, but the worst of them all was the steroid called prednisone (anyone who has been on these can sympathise with me). These are truly the worst steroids in the world, I gained so much weight, I suffered from moon face, which made me look like a chipmunk (and not a cute one). I started receiving Infliximab (Remicade) infusions every two months, which is an auto-immune suppressant drug used to treat IBD."

Patient 2:

"I thought I could get it under control quickly and everything would go back to the way it was. I was wrong. The first six months after diagnosis were hell on earth. I developed severe anxiety about leaving the house as a result of my illness and symptoms. I tried to return to work and then became depressed when I failed miserably. My relationship ended. I had no appetite and couldn’t put back on the weight which resulted in me feeling really badly about my body and appearance.

I was taking steroids called Prednisone for the first three months and they made my face swell up, my hair fall out and also added massively to the anxiety and depression I was already dealing with. I began getting Infliximab (Remicade) infusions to suppress my immune system every eight weeks. That eventually had to be changed to every six weeks because my symptoms were still quite severe and the medication wasn’t lasting long enough.

Fourteen months down the line after diagnosis I am still struggling. "


Question 3) What are the current computational advances to resolve diagnostic uncertainty for health professionals such as the one described in patient 4? Go through this article: https://bmcmedinformdecismak.biomedcentral.com/articles/10.1186/s12911-020-01277-w and list the differences in the endoscopy findings between ulcerative colitis and intestinal tuberculosis identified by the Random forest and CNN model. Go through the colonoscopic descriptions captured in the patient 4 online EMR linked above and share your insights on what could be the probable diagnosis. Please share your current general knowledge thoughts or similar past experiences in diagnostic uncertainty while dealing with patients with potential inflammatory bowel disease and how you resolved them. 

Question 4)

List the current therapeutic strategies for IBD and share your critical appraisal of a few RCTs around each option, not only those mentioned in the patient narratives above such as SAIDs like prednisolone and biologicals like infliximab but also NSAIDs such as meselamine and immunomodulators such as azathioprine. 

Advocacy and pluralistic integration of available solutions as a therapeutic tool.

Patient 3:

 "I tried Allopathy, Ayurveda, Naturopathy, etc. They helped me to some extent, they helped to be alive, but not helped me to the extent I wanted. Then I thought let me try YOGA."

Quoted from here:

 
Patient 5:

"You see, it’s really difficult to live with Crohn’s or ulcerative colitis as it is but in many cultures around the world, there is little to no acceptance of young people who have chronic illnesses. And even though I live in cosmopolitan New York City, I have had one foot in two cultures: the country of my origin, India, and the country of my birth, the United States. According to South Asian culture, I was supposed to be taking care of my widowed mother, not being a burden on her. I was supposed to be out working my Wall Street job and supporting my family, not being a frequent flyer on the IBD floor of my hospital. As the oldest child of the family with no father and no brothers, my role was to take care of my family, not be the person being constantly taken care of."

Quoted from here :


Question 5) What is the role of the internet and it's patient users toward driving their own healthcare outcomes through timely sharing of their problems and pluralistic solution inputs from patient advocates and health professionals? What is the role of a doctor patient relationship in healing outcomes as demonstrated in some of the narratives? Please share your own experiences where you were part of one such relationship that worked positively or negatively for your patient. What is the role of computational ML AI in considerably expanding this "user driven healthcare" space? Please search for clinical decision support projects that begin with "applications that assign SNOMED CT codes to entered patient data which in turn trigger decision support information." 

Check out how these can be further expanded using ML AI techniques to create knowledge graphs toward 

"1) Named-Entity Recognition — given a patient’s initial complaint, the NER should tag medical and clinical entities.
2) Classification — e.g. classify an initial patient chat as an informational session or requires a visit to a hospital.
3) Diagnosis — ability to provide a diagnosis (with certain probability) given a chat session


Finally to sign out on a note around the disease theme in this question paper, from your own user perspective, please critically appraise this paper that develops an "ontology encapsulating IBD physicians knowledge
and describes different characteristics such as classification, medi-
cation, the activity of the disease, diagnosis techniques and various
other IBD attributes along with generating a knowledge graph by
importing 560 patient records collected in their University Hospital ontology." 


Further reading:

Book chapter:


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