General Medicine Assignment 2

 

Question 1: Competency tested for Peer to peer review and assessment : 

 

Please go through one student's entire answer paper from this link, the one who is closest to your own roll number :

 

http://medicinedepartment.blogspot.com/2021/07/2019-batch-medicine-department-online.html?m=1

 

and share your peer review of each answer with your qualitative insights into what was good or bad about the answer.

 

Answer 1: Link chosen- https://seemalaanjali123.blogspot.com/?m=1 

Peer review:

·       Answer 1: Answer has not been clearly labelled. Patient history has been taken into account for provisional diagnosis. Proper justification of diagnosis is given. Diagrams have been inserted where necessary. In Patient care has been recorded. Drugs used have been written. Drug function and mechanism of action have not been written.

·       Answer 2: Not attempted

·       Answer 3: The disease has been identified and defined. Pathology of the disease has also been explained well.

·       Answer 4: All investigations done have been listed. Drugs and reason for usage has been written however mechanism is not.

·       Answer 5: Accurate feedback has been given.

·       Overall: the questions should also have been written for convenience of the examiner. Points should have been labelled and differentiated in a more readable manner. Other than that, all attempted questions have been answered satisfactorily.

·        

Question 2: Share the link to your own case report of a patient that you connected with and engaged while capturing his/her sequential life events before and after the illness and clinical and investigational images along with your discussion of that case.

 

Answer 2: https://shaardul124.blogspot.com/2021/07/3rd-sem-general-medicine-e-log.html

 

Question 3: (Testing peer review competency of the examinees): Please go through the cases in the links shared above and provide your critical appraisal of the captured data in terms of completeness, correctness and ability to provide useful leads to analyse the diagnostic and therapeutic uncertainties around the cases shared.

Answer 3:

1.     AKI- https://laharikantoju.blogspot.com/2021/07/58-year-old-male-patient-elog-lahari.html?m=1

a.     Completeness- Rigorous and complete history has been taken except height, weight, BMI and BSA measurements, which are lacking. All investigations have been listed, and only values of concern have been written down which is convenient, photos of radiographs have also been inserted. Provisional diagnoses have been listed. Treatment plan has been included with doctor’s instructions and drugs. However, the reason for administration of drugs is missing.

b.     Correctness- All the information seems to be in order.

c.      Ability to provide useful leads to analyse the diagnostic and therapeutic uncertainties around the case- Leads are offered for further investigation and research in the provisional diagnosis.

2.     CKD- https://krupalatha54.blogspot.com/2021/07/a-49-yr-old-female-with-generalized.html?m=1

a.     Completeness- Rigorous and complete history has been taken. All investigations have been listed, and only values of concern have been written down which is convenient, photos of radiographs have also been inserted. Provisional diagnoses have been listed. Treatment plan has been included with doctor’s instructions

b.     Correctness- all information seems to be in order.

c.      Ability to provide useful leads to analyse diagnostic and therapeutic uncertainties- Leads are offered for further investigation and research in the provisional diagnosis.

3.     Acute onset CKD: https://srinaini25.blogspot.com/2021/07/srinaini-roll-no-33-3rd-semester-this.html

a)     Completeness- Rigorous and complete history has been taken. All investigations have been listed, and only values of concern have been written down which is convenient, photos of radiographs have also been inserted. Provisional diagnoses have been listed. Treatment plan has been included with doctor’s instructions

b)     Correctness- all information seems to be in order.

c)     Ability to provide useful leads to analyse diagnostic and therapeutic uncertainties- Leads are offered for further investigation and research in the provisional diagnosis.

4.     Coma and renal failure: https://ananyapulikandala106.blogspot.com/2021/06/a-35yr-old-female-elog.html

a.     Completeness- Rigorous and complete history has been taken. All investigations have been listed, and only values of concern have been written down which is convenient, photos of radiographs have also been inserted. Provisional diagnoses have been listed. Treatment plan has been included with doctor’s instructions

b.     Correctness- all information seems to be in order.

c.      Ability to provide useful leads to analyse diagnostic and therapeutic uncertainties- Leads are offered for further investigation and research in the provisional diagnosis.

 

Question 4: Testing scholarship competency of the examinees (ability to read comprehend, analyse, reflect upon, and discuss captured patient cantered data as in their 'original' answers to the assignment for May 2021):

Please analyse the above linked patient data by first preparing a problem list for each patient (based on the shared data) and then discuss the diagnostic and therapeutic uncertainty around solving those problems. Also include the review of literature around sensitivity and specificity of the diagnostic interventions mentioned and same around efficacy of the therapeutic interventions mentioned for each patient. 

 

Answer 4:

1.     AKI-  https://laharikantoju.blogspot.com/2021/07/58-year-old-male-patient-elog-lahari.html?m=1

a.     Problem list-

                                                  i.     Lower abdominal pain

                                                 ii.     Burning micturition

                                                iii.     Lower back pain

                                                iv.     Dribbling of urine

                                                 v.     Decrease in urine output

                                                vi.     Fever

                                              vii.     Shortness of breath

                                             viii.     Elevated serum creatinine

b.     Literature review around sensitivity and specificity of diagnosis- serum creatinine has 90% specificity and sensitivity in diagnosing AKI. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3695762/

c.      Literature review around efficacy of therapeutic interventions- Among pharmacologic agents, mannitol appears to have a positive prophylactic effect in kidney transplantation. There are no other significant beneficial effects of diuretics for prophylaxis or as treatment in early or established ARF. Of vasoactive agents, there is a relatively small amount of data suggesting that diltiazem may have a positive prophylactic effect in kidney transplantation, and dopamine possibly is beneficial early in the evolutionary phase of ARF. Atrial natriuretic peptide and calcium channel blockers may have beneficial effects in established disease. No other pharmacologic interventions are supported by substantial data. There is no clear evidence that one form of nutritional therapy has advantages over others, but some level of amino acid supplementation in addition to basic energy replacement is supported by the overall data. https://pubmed.ncbi.nlm.nih.gov/7573008/

2.     CKD- https://krupalatha54.blogspot.com/2021/07/a-49-yr-old-female-with-generalized.html?m=1

a.     Problem list-

                                                  i.     Muscle aches

                                                 ii.     Generalised weakness

                                                iii.     Pallor- dimorphic anaemia 

                                                iv.     Elevated serum creatinine

                                                 v.     Elevated blood urea

                                                vi.     Pus in urine

                                              vii.     Diastolic dysfunction

                                             viii.     Mild to moderate suppression of all bone marrow cell lines

                                                ix.     Plasma cell dyscarasia

                                                 x.     M band in electrophoresis  

b.     Literature review around sensitivity and specificity of diagnosis- eGFR <45 mL/min of 28% and a specificity of 94%. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4894343/

c.      Literature review around efficacy of therapeutic interventions- RAS blockade with angiotensin converting enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARBs) is the cornerstone therapy to reduce proteinuria, CKD progression, and cardiovascular risk. Renin inhibitor therapy is useful for individuals intolerant to above therapy. Spironolactone and the more selective aldosterone antagonist eplerenone have substantial antihypertensive, cardioprotective, and antiproteinuric effects even at low doses, and in the presence of combined ACEi and ARB therapy. SGLT2 inhibitors have shown remarkable additional benefits in delaying CKD progression on top of the standard RAS blockade. https://www.frontiersin.org/articles/10.3389/fmed.2021.645187/full

3.     Acute onset CKD: https://srinaini25.blogspot.com/2021/07/srinaini-roll-no-33-3rd-semester-this.html

a.     Problem list-

                                                  i.     Lower back pain

                                                 ii.     Dribbling of urine

                                                iii.     Pedal oedema

                                                iv.     Shortness of breath

                                                 v.     Involuntary movements of upper limbs

                                                vi.     Slurred speech

                                              vii.     Increased tone in lower limb

                                             viii.     Hyperuricemia

                                                ix.     Elevated serum creatinine

                                                 x.     Anaemia

                                                xi.     Lymphocytosis

                                              xii.     Hyperphosphatemia

                                             xiii.     Spondylodiscitis

b.     Literature review around sensitivity and specificity of diagnosis- Spondylodiscitis and osteomyelitis are seen in end-stage renal disease (ESRD) patients due to repeated vascular access for hemodialysis and urinary tract infections leading to recurrent bacteremia. Discitis and osteomyelitis are underdiagnosed due to the nonspecific initial presentation of back pain. https://pubmed.ncbi.nlm.nih.gov/30771765/

c.      Literature review around efficacy of therapeutic interventions- RAS blockade with angiotensin converting enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARBs) is the cornerstone therapy to reduce proteinuria, CKD progression, and cardiovascular risk. Renin inhibitor therapy is useful for individuals intolerant to above therapy. Spironolactone and the more selective aldosterone antagonist eplerenone have substantial antihypertensive, cardioprotective, and antiproteinuric effects even at low doses, and in the presence of combined ACEi and ARB therapy. SGLT2 inhibitors have shown remarkable additional benefits in delaying CKD progression on top of the standard RAS blockade. https://www.frontiersin.org/articles/10.3389/fmed.2021.645187/full

4.     Coma and renal failure: https://ananyapulikandala106.blogspot.com/2021/06/a-35yr-old-female-elog.html

a.     Problem list-

                                                  i.     Fever

                                                 ii.     Diarrhea

                                                iii.     Back pain

                                                iv.     Type 2 diabetes mellitus

                                                 v.     Hyperglycemia

                                                vi.     Went into diabetic ketoacidosis coma

                                              vii.     Pyelonephritis

                                             viii.     Lymphocytosis

                                                ix.     Anemia

                                                 x.     Hyperbilirubinemia

                                                xi.     Elevated ALP

                                              xii.     Uremia

                                             xiii.     Elevated serum creatinine

b.     Literature review around sensitivity and specificity of diagnosis- MRI is 86.8% sensitive and 87.5% specific. CT 74.3% sensitive and 56.7% specific for diagnosing pyelonephritis. https://pubmed.ncbi.nlm.nih.gov/11152787/

c.      Literature review around efficacy of therapeutic interventions- “Our successful management of this patient lies in the following points: 1. We confirmed the diagnosis of EPN by urinary CT examination as soon as the patient was admitted to hospital; 2. Rapid correction of ketoacidosis by continuous intravenous infusion of low-dose insulin and fluid resuscitation; 3. We performed blood culture before using antibiotics and upgraded cefoperazone sulbactam to meropenem according to the results of blood culture and the antibiotic-susceptibility test results; 4. Our endocrinology department collaborated with urology, nephrology, infection and imaging departments to develop a treatment plan.” https://bmcurol.biomedcentral.com/articles/10.1186/s12894-020-0575-0