Past projects around the above context in the links below :
UG student thesis 2003:
UG student thesis 2005:
PG student thesis : 2012-13
November 19, 2021
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 :
Case report link : https://prashanthsharma101.
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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