Intern online Assessment
Intern assessment
Name :B.Sushma
Posted from 11/8/2022 till 11/10/2022
Current online learning portfolio (OLP) linked here 👉
Learning impact assessment from cases recorded in OLP :
CASE 1)
51 year male with foot drop and ulcer
https://bonthusushma154.blogspot.com/2022/09/51-year-old-male-with-foot-drop.html
Learning impact--
Discussion in class:
Question 1:
Why was biopsy not done in ulcer region i-e lateral aspect of plantar region
Answer 1:
According to dermatology referral there was Swelling around the ulcer it may also be suggestive of mycetoma so dermatology people can't tell if ulcer heals or not if they have done biopsy at ulcer region so they are not ready for aggravating it and have taken biopsy from area below the shin of tibia
Question 2:
What is wallerian degeneration and how is it related to infective or any other inflammatory injury including trauma?
How are neurodegenerative disorders different in terms of their neuronal degeneration?
Answer 2.
https://jneuroinflammation.biomedcentral.com/articles/10.1186/1742-2094-8-109
The characteristics of an efficient innate-immune response are rapid onset and conclusion, and the orchestrated interplay between Schwann cells, fibroblasts, macrophages, endothelial cells, and molecules they produce. Wallerian degeneration serves as a prelude for successful repair when these requirements are met. In contrast, functional recovery is poor when injury fails to produce the efficient innate-immune response of Wallerian degeneration.
Online discussion
[9/14, 9:56 AM] Rakesh Biswas: Good. In the diagnosis you need to mention the involved nerve and the fact that it is a mono neuropathy
[9/14, 9:58 AM] Rakesh Biswas: Check out the video of another mononeuropathy published by our elective students long back here 👇
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4785487/
[9/14, 10:24 AM] Rishika 2019.kims 112: Done sir
[9/14, 10:35 AM] Rakesh Biswas: Are you sure it's common peroneal and not distal to that? The patient's clinical signs suggest he has got good power in calf muscles as well as sensation over it's dermatome? Which nerve supplies there? And which nerve supplies till the dorsum which is the most affected?
[9/14, 11:41 AM] Riya Gupta 2019 Kims Ug: Sir the calf muscles are being supplied by the tibial nerve and the patient is able to plantarflex . The major part of the sensory supply of dorsum is supplied by the superficial peroneal nerve ( branch of common peroneal) . The sensory supply of the foot also involve other nerves like Sural nerve , Saphenous nerve and distal branches of the Tibial nerve in the plantar aspect .He is not able to dorsiflex due to the involvement of the deep peroneal nerves .
[9/14, 11:42 AM] Riya Gupta 2019 Kims Ug: Sir since there is no sensation in the entirety of the foot , could this be a polyneuropathy ?
[9/14, 11:42 AM] Rishika 2019.kims 112:
https://www.ncbi.nlm.nih.gov/mesh/68020427
Peroneal Neuropathies
Disease involving the common PERONEAL NERVE or its branches, the deep and superficial peroneal nerves. Lesions of the deep peroneal nerve are associated with PARALYSIS of dorsiflexion of the ankle and toes and loss of sensation from the web space between the first and second toe. Lesions of the superficial peroneal nerve result in weakness or paralysis of the peroneal muscles (which evert the foot) and loss of sensation over the dorsal and lateral surface of the leg.
[9/14, 11:42 AM] Rishika 2019.kims 112: Tibial Neuropathy
Clinical features include PARALYSIS of plantar flexion, ankle inversion and toe flexion as well as loss of sensation over the sole of the foot. (From Joynt, Clinical Neurology, 1995, Ch51, p32)
Year introduced: 2000
https://www.ncbi.nlm.nih.gov/mesh/68020429
[9/14, 11:45 AM] Rishika 2019.kims 112: Yes sir
[9/14, 11:47 AM] Rishika 2019.kims 112: Suggestive of deep peroneal nerve involvement -
-Absence of dorsiflexion
-loss of sensation in first web space
Suggestive of tibial involvement-
Loss of sensation over sole of foot
[9/14, 8:53 PM] Rakesh Biswas: Thanks. Well analyzed both of you 👏
So do we have the findings in this particular patient that we have now reviewed in terms of general knowledge?
We know our patient has findings of PARALYSIS of dorsiflexion in his ankle and toes and loss of sensation from the web space between the first and second toe suggestive of deep peroneal?
CASE 2)
39 year female with fever and polyserositis
https://bonthusushma154.blogspot.com/2022/09/september-9th2022-this-is-online-e-blog.html
Online discussion
Question
Viral sepsis!
Answer
Yes sir sepsis score>2
[9/10, 8:45 AM] +91 91210 46928: Very nice record for the fever project
CASE 3)
57 year female with fever and thrombocytopenia
https://bonthusushma154.blogspot.com/2022/09/57-yr-female-with-fever-thrombocytopenia.html
During presentation in class
Question 1)
Any SDP transfusion given
Answer 1)
No sir
Question 2)
What are the counts of platelets since admission
Answer 2)
Day 1-10,000
Day 2-15,000
Day 3-45,000
Question 3)
What was the reason for SDP transfusion in the other case with platelets 10,000 but without transfusion platelet count has increased in this case
Answer 3)
Immunity
CASE 4)
50 year female medicine referral i/v/o paralytic ileus surgery
https://bonthusushma154.blogspot.com/2022/09/september-1st-2022-this-is-online-e.html
- 8A single heavy episode of drinking can damage the mucous cells in the stomach, and induce inflammation and lesions.19
- High alcohol content beverages (more than 15% alcohol volume) can delay stomach emptying, which can result in bacterial degradation of the food, and cause abdominal discomfort.20
CASE 5)
34 year male with seizures
https://bonthusushma154.blogspot.com/2022/08/34-year-male-with-seizures.html
Online discussion:
Patient is having anemia
[9/1, 4:33 PM] Raveen Sir Pg Y3: Found an interesting article
Anemia among cerebral palsy
It’s not per se decreased iron intake
It might be absorption.
[9/1, 4:35 PM] Raveen Sir Pg Y3: In general, iron deficiency anemia due to inadequate iron intake is rare. There are some reports of such epi- demics in areas with high incidence of hookworm infection, or in areas with low consumption of meat in which nutrition is based mainly on vegetables, cereals and rice. Such foods contain phytates and polyphenols which are strong inhibitors of iron absorption. However, iron deficiency anemia due to low iron intake is extremely rare in Western countries.
[9/1, 4:35 PM] +91 91210 46928: Specify the questions in this patient.
I can see one of them is why anemia
So what have we found? Let's discuss that before we jump to what others found in their cerebral palsy patients
[9/1, 4:37 PM] Raveen Sir Pg Y3: Based on phytates and polyphenols
[9/1, 4:38 PM] +91 91210 46928: This paragraph looks speculative as there is no data to support it?
@Aditya Samitinjay Can you share some data driven work that shows the correlation between poor nutrition and iron deficiency?
[9/1, 4:40 PM] Raveen Sir Pg Y3: ite the presence of adequate organic acids and little phytate. It was then observed that the other vegetables, including brown and green lentils and beetroot greens, that showed marked colour changes on the addition of Fe, were also associated with poor Fe bioavailability. The total and extractable phenol contents of all the vegetables on which Fe absorption measurements had been done were therefore determined, and a strong inverse correlation between the total polyphenol content and Fe absorption was found ( r- 0-859, P < 0.001). The fact that the inverse correlation was even greater when the extractable polyphenol content had been subtracted from the total value (r-0-901;P < 0.001) suggested that it was the non-hydrolysable condensed polyphenols that were responsible for the inhibitory effect on Fe absorption.
[9/1, 4:41 PM] +91 91210 46928: What is the Hb, peripheral smear and serum ferritin in our patient?
[9/1, 6:59 PM] Vamsi Krishna Sir Pg 3: Hb 8.1
Smear: Normocytic Normochromic sir
[9/1, 7:05 PM] Vamsi Krishna Sir Pg 3: Yes sir we thought of iron deficiency because of poor intake & absorption in cerebral palsy
[9/1, 7:06 PM] +91 91210 46928: How does one make the diagnosis of iron deficiency anemia?
Can we just make it because it has been noticed in cerebral palsy or shouldn't we confirm iron deficiency by standard methods first?
[9/1, 7:07 PM] Vamsi Krishna Sir Pg 3: Peripheral smear in our patient is Normocytic Normochromic which can still be iron deficiency as stated in this article sir
[9/1, 7:14 PM] +91 91210 46928: How do you confirm iron deficiency? Have we done those?
[9/1, 7:15 PM] +91 90001 66698: Peripheral smear in our patient also shows increased RDW,suggesting dimorphic anemia/anisocytosis or even poikilocytosis.
Which can be commonly seen in anemia of chronic disease?
[9/1, 10:56 PM] Raveen Sir Pg Y3: I shared this before in the group sir
Based on hemogram we can come to an assessment
But definitive is bone marrow
[9/1, 10:58 PM] Raveen Sir Pg Y3: Yes sir
That was what the article was showing
Anemia in cerebral palsy
Overall iron deficiency is more common
If going by hemogram
MCV is normal
Apart from increase in RDW
[9/1, 10:59 PM] Raveen Sir Pg Y3: And also if nutrional cause where even proteins are low
Like he has an albumin of 3.2 on a lower limit
[9/1, 11:03 PM] +91 91210 46928: What did the patients in that article go by? How was their diagnosis confirmed?
Why bone marrow alone? What is the specificity of serum ferritin?
[9/1, 11:08 PM] +91 91210 46928: So we can say their diagnosis wasn't confirmed?
[9/1, 11:08 PM] Raveen Sir Pg Y3: Will have to review for specificity
Going by system 1
Ferritin is an acute phase reactant and not a reliable marker 😅
[9/1, 11:09 PM] +91 91210 46928: Yes so if it's high not reliable but when it's low? Is there any other cause for low ferritin?
[9/1, 11:11 PM] Raveen Sir Pg Y3: It might be sir
What about in a state of inflammation
Ultimately going by objective evidence of bone marrow biopsy would be confirmed in any case ?? 😅
[9/1, 11:32 PM] Raveen Sir Pg Y3: Found an article showing not with a comparitator
Intervention of IV Iron with out an EPO in CKD patients
Couldn’t steal the article
https://pubmed.ncbi.nlm.nih.gov/16736414/
[9/1, 11:33 PM] Raveen Sir Pg Y3: P - Forty-seven consecutive patients with CKD with Hb <12 g/dL in whom no underlying cause for the anemia could be found underwent sternal bone marrow biopsy and had their red cell and blood iron parameters measured.
I - received 250 mg of ferric gluconate (Ferrlecit) intravenously twice monthly for 3 months, and had their blood parameters measured 1 month later. No patient received erythropoietin (EPO)
C -
O - Forty-six patients had no evidence of any iron deposits in the bone marrow - consistent with the presence of severe iron deficiency. The mean serum ferritin and %transferrin saturation prior to treatment were 235.9 +/- 54.3 ug/L and 13.5 +/- 4.1%, respectively, and both increased significantly with the iron treatment. Mean Hb increased from 10.16 +/- 1.32 to 11.96 +/- 1.52 g/dL, an increase of 1.80 +/- 1.72 g/dL (p<0.01). Twenty-six patients (55.3%) reached the target Hb of 12 g/dL. Ten patients (21.3%) had an increase of 0.1-0.9 g/dL, nine patients (19.1%) had an increase of 1-1.9 g/dL and 23 patients (48.9%) had an increase of >or= 2 g/dL.
[9/1, 11:34 PM] +91 90001 66698: This study is done on CKD patients not on dialysis
[9/1, 11:34 PM] Raveen Sir Pg Y3: Yes
CASE 6)
52 year male with loin pain and sob
https://bonthusushma154.blogspot.com/2022/08/52-year-male-loin-pain-and-sob.html
CASE 7)
40year male with fever and thrombocytopenia
https://bonthusushma154.blogspot.com/2022/08/40-year-male-with-fever.html
Learning points:
Question 1)
Any SDP transfusion has been done?
Answer 1)
Yes sir
Question 2)
What was indication of SDP and what was the platelet count
Answer 2)
platelet count is of 7000 and bleeding manifestons are present in this patient
CASE 8)
45year female with thrombocytopenia
https://bonthusushma154.blogspot.com/2022/08/45-year-female-with-thrombocytopenia.html
During Rounds in ICU and AMC
Question 1)
Any transfusion had occurred and What was the platelet count
Answer 1)
No transfusion has taken place and patient condition is improving and no fever spikes and platelet count also increased
and planning for discharge
CASE 9)
26 year female with headache
https://bonthusushma154.blogspot.com/2022/08/26-year-female.html
I have taken this patient for surgery and psychiatry referrals
[8/23, 6:32 PM] +91 91210 46928: Surgery review
[8/23, 6:35 PM] +91 91210 46928: Now to tackle her Chronic headache we need a good history
[8/30, 9:02 PM] +91 85199 76747: We could take another psychotherapy session with the patient and her husband. She should be able to cope with the continued help from the whole team of general medicine through PaJR group going forward
CASE 10)
42year old male with altered sensorium
https://bonthusushma154.blogspot.com/2022/08/42-year-old-male-with-altered-sensorium.html
Online discussion
This patient serum cortisol is 0.54mcg/dl confirming adrenal insufficiency
Diagnosis: Hypovolaemic hyponatremia secondary to mineralocorticoid deficiency
[8/15, 6:00 PM] Vamsi Krishna Sir Pg 3: Plan: Further evaluation to look for central/peripheral cause & starting of steroids for further management
[8/15, 6:01 PM] +91 91210 46928: Does a serum cortisol test confirm anything if the serum cortisol levels are low or confirms absence of adrenocortical insufficiency when the serum cortisol levels are high?
In other words the serum cortisol levels can only rule out adrenocortical insufficiency but not rule it in?
[8/15, 6:16 PM] Vamsi Krishna Sir Pg 3: Serum cortisol concentrations are normally highest in the early morning hours (06:00h – 08:00h), ranging between 10 – 20 mcg/dL (275 – 555 nmol/L) than at other times of the day.
*Serum cortisol concentrations determined at 08:00h of less than 3 µg/dL (80 nmol/L) are strongly suggestive of adrenal insufficiency.*
[8/15, 6:18 PM] +91 91210 46928: Does strongly suggestive mean confirmed adrenocortical insufficiency?
Even if the levels are high in the morning what are the chances that they can be low due to pulsatile release one fine morning?
[8/15, 6:49 PM] +91 91210 46928: "Additionally, basal serum cortisol cannot be used for patients who have low CBG levels. Because 80% of cortisol is bound to CBG, and because assays measure total protein-bound cortisol, a decrease in binding proteins will accordingly alter serum cortisol concentrations."
Additionally, polymorphisms in CBG can also exist and may contribute to low levels of total cortisol. Single-nucleotide polymorphisms in CBG can explain why CBG levels in some individuals are approximately 50% lower than normal"
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6873870/
[8/15, 6:51 PM] +91 91210 46928: 👆@Vaishnavi Karnati this case report reminds me of yours. Very interesting causes for low serum cortisol discussed
[8/15, 10:15 PM] +91 83746 10190: Yes sir it's true
We never go by one basal serum cortisol levels . We've always followed it by stimulation test which is the standard protocol for diagnosing adrenal insufficiency.
Cushing on the other hand is more a clinical diagnosis backed up by Overnight dexamethasone suppression test or 24 urinary cortisol
Even in CS we do suppression test ,so its never one value as such we should rely on
[8/15, 10:16 PM] +91 83746 10190: Basal cortisol levels do get effected by drugs like fluconazole like in our case , pregnancy ,anti-epileptics etc
[8/15, 11:12 PM] +91 91210 46928: 👍
My GENERAL MEDICINE Posting days
From 12/08/2022 to 11/09/2022 I was posted in units and I have followed my unit cases,I have updated fever chart,I have followed the discussion about my cases in online groups and offline also which are admitted and I have attended every day rounds under Rakesh Biswas sir (HOD) and PG's and attended classes in clinical lecture hall and dhanvantri and I have kept foleys for female patient under the guidance of DMO in casuality on Sunday on my duty day under my unit PG's Dr.Vamsi Krishna sir PG Y3,Dr Hari Priya mam PG Y1.
From 12/09/2022 to 16/09/2022 i was posted in nephrology under Dr.Shashikala mam PG Y3 and Dr.Nishitha mam PG Y1 I have monitored patient vitals for every 30mins who are undergoing dialysis and I have sent cross matching samples and collected blood from blood bank and I have checked if all dialysis patients were taking there medication on time or not and typed discharge summary of few patients and I have learnt suturing and sutured in presence of Dr.Shashikala mam.
From 17/09/2022 to 21/09/2022 i was posted in ICU under Dr.Vinay sir PG Y3 and Dr.Raveen sir PG Y3 and DrNarsimha sir PG Y1. During my ICU postings they are 4ventilator cases and I have taken vitals every hourly and I have learnt ABG sample under guidance of Dr.Vinay sir PG Y3 and then collected samples of patients and I have kept Ryles tube for one of the ventilator patient and I have kept foleys for female(Admitted under unit 1)and male(Admitted under unit 2)patients and attended rounds in ICU and AMC . And also I have done suturing under guidance of Dr .Venkat sir and Dr.Nishitha mam
From 22/09/2022 to 26/09/2022 i was posted in ward and during my ward duties I made my co interns to update SOAP notes,Fever charting and I have updated new admission cases in 2k17 Elog medicine group and took videos of our jr presentation , I have monitored patients in super speciality ward and medical ward patient during my night duties under concerned unit PG's And I also helped our long distance patients by taking them to referrals and getting investigations done on time and I was there in night duty for one long distance patient to undergo blood transfusion and checked vitals before , during and after transfusion to correct his HB to 10 so that he can undergo nephrectomy surgery
From 27/09/2022 to 11/10/2022 i was posted in psychiatry
Offline presentation:
I have presented my case in dhanvantri in front
of Dr.Rakesh Biswas sir (HOD ), and our unit PGs Dr.Vamsi Krishna sir (PG Y3),Dr.Hari Priya mam (PG Y1)
Procedural videos:
- I have kept 3foleys catheter and 1ryles
- I have done ascitic tap
- Took ABG samples and venous sample
- I have done suturing
1) I have kept foleys for a female patient in casuality under the guidance of DMO mam in casuality on Sunday
2) I have kept foleys for a female patient in ICU admitted under unit 1 under the guidance of Dr.Pavan Kumar sir (PG y1) and Dr.Narsimha sir (PG y1)
3) I have kept foleys for a 21 year old male patient with altered sensorium in ICU admitted under unit 2 under the guidance of Dr.Raveen sir (PG Y3)
4) I have kept Ryles for 54 year old male with community acquired pneumonia in ICU admitted under unit 5 under the guidance of Dr.Narsimha sir (PG Y1)
5)I have done ascitic tap for female patient in AMC admitted under unit 1 under the guidance of Dr.Kranthi sir (PG y1)
6)I have done suturing after central line has placed once under the guidance of Dr.shashikala Mam (PG Y3) and Dr.Nishitha mam (PG y1)
7) I have done suturing for the second time after the triple line for drugs has placed under the guidance of Dr.Venkat sir (PG Y1) and Dr.Nishitha mam (PG Y1)
