" MY EXPERIENCES WITH GENERAL CELLULAR AND NEURAL CELLULAR PATHOLOGY IN A CASE BASED BLENDED LEARNING ECOSYSTEM'S CBBLE"
In the era of evidence -based practice, we need practice- based evidence.
The basis of this evidence is the detailed information from case reports of individual people which informs both our clinical research and our daily clinical care.
Hello and welcome to my blog!
I'm Shivang Sharma, a passionate med student from India. Here,I share well organized, aesthetically,critically evaluated personal experience of my medical journey with enhanced patient interaction skills and overall patient approach in my med school.
I'd truly appreciate my professors ,seniors for you and your time spent helping me in many occasions for challenging me to think critically and providing me with the tools ,I need to succeed not only in med school, but in life.
I want to share some insights of information on particular treatments,medications and diseases, for more inventive health care education system.
CBLE PAJR PARTICIPATORY LEARNING ACTION
RESEARCH DISCLAIMER
NOTE : This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centred online learning portfolio and your valuable comments on comment box is welcome. I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.
The best doctors in hospital were one who made connections with the patients they were treating. Simple things like remembering their name and knowing where they live made an immense difference in the way those doctors interacted with their patients. Seeing things from patients perspective makes for very satisfying life as a doctor.
So , let's get started with one of the interesting case till now in my entire med school journey.
CASE : He was 37 year old male,is a resident of coochbehar of west Bengal and came with chief complaints of lower back ache since 10 months.
Before proceeding for further information, I asked ,whether he was comfortable with hindi language, since he was from Bengal native. So,seemingly he could speak hindi.
I started inquiring his present illness, so, the patient started working as employee in private company, he uses bike to do some of the transport work.(duration- 2 to 3 hours per day)
Due to the progressive nature of pain he stopped riding bike 3months back
He was apparently asymptomatic 10months back then he developed low back ache which was insidious in onset ,gradually progressive, non radiating type ,continuous ,it aggravates on sitting for longer duration and also associated with tingling sensation so he unable to sit for longer duration, and has no relieving factors. He stopped lifting heavy weights because of back pain.
I stared investigating regarding medicines to relieve pain. Whether he tried to prescribe his own medication or went for consulting a doctor? Patient replied: as in,to relieve the pain from nearby pharmacy which was of no use , so he consulted a doctor in a local hospital in aug 2022 where he was investigated (mri and x ray was done)and was diagnosed as lumbar spondylosis and was given 6 injections Rejunuron on alt days followed by 4 injections of decadurabolin 50mg for every 3 weeks but there was no relief for the patient and was also diagnosed with hypertension and using tab .clinidipine 10mg since then .
Patient started having pain(which is non radiating,burning type of pain) and tingling sensation in left foot and upper limb-
left hand fingers since 4 months insidious in onset ,intermittent in nature so he again consulted the doctor was given medication ( tab.nervite plus for 3 weeks ) and advised for surgery if the pain has not resolved further.
Inquiring the past history of the patient, he got diagnosed with k/c/o Hypertension since 9 months on medication (tab.clinidipine 10 mg).k/c/o Lumbar spondylosis since 9 months.
Not a k/c/o dm,tb,epilepsy,asthma,thyroid disorders,no history of trauma.No history of surgeries.
there wasn't any significant familial history.
Patient completed his education until 7th standard, he got married in 2011 have two kids ,1st child is female 11 yrs old and 2nd child boy 11 months. He is an employee in private company since 2008 . He regularly starts for work at 10 am and mostly travel on bike for the work related to company until 2pm and then he takes his lunch and sits in work place from 3 pm to 10 pm . Later he goes home have dinner and sleep by 12 am.
Patient stopped working since feb 2023 because of sever backpain and also stopped riding bike .Diet is mixed ,normal appetite with adequate sleep and regular bowel and bladder movements. Had a habit of taking alcohol occasionally since 2015 but stopped consuming completely since 1 and half year.No allergic history.
https://shivangsharmarollno145.blogspot.com/2023/05/a-37year-old-male-with-lower-back-ache.html.
The final diagnosis of the patient was lumbar spondylosis.
Discussion:
[18:19, 29/05/2023] Shivang sharma 15/05, 10:02 pm] Rakesh Biswas HOD: What are the questions identified?
[15/05, 10:11 pm] Kshitij Kims: Sir
Can his Hypertension by treated by non-pharmacologic method?
His lifestyle seems like a cause for his Hypertension!
[15/05, 10:18 pm] Kshitij Kims: Postural syndrome! @Manogna Kims how long does he drives for (Distance ) and (duration) !
Considering the roads , the aforementioned factors can play significant role
[15/05, 10:20 pm] +91 94914 18555: How would postural syndrome cause Hypertension in this patient?
[15/05, 10:26 pm] Kshitij Kims: Not the postural syndrome!
[15/05, 10:27 pm] Kshitij Kims: Hypertension might be a result of his lifestyle
[15/05, 10:27 pm] Shivang Sharma: It can causes lumbar spondylosis
[15/05, 10:28 pm] Shivang Sharma: Long-term, repetitive strain on your low back, whether occupational or recreational can causes lumbar spondylosis
[15/05, 10:36 pm] Kshitij Kims: https://pubmed.ncbi.nlm.nih.gov/9894438/
[15/05, 10:36 pm] Kshitij Kims: Stress can cause hypertension through repeated blood pressure elevations as well as by stimulation of the nervous system to produce large amounts of vasoconstricting hormones that increase blood pressure. Factors affecting blood pressure through stress include white coat hypertension, job strain, race, social environment, and emotional distress. Furthermore, when one risk factor is coupled with other stress producing factors, the effect on blood pressure is multiplied
[15/05, 10:37 pm] Manogna Kims: Q. In this case, the patient apparently claimed that the pain was not reduced even after going to physiotherapy or any other medications,
So how will we proceed sir?
[15/05, 10:40 pm] Kshitij Kims: Do we have his x-ray and mri from aug 2022?
[15/05, 11:01 pm] Kshitij Kims: Well! Let's find out the JOA SCORE for this pt. !?
[15/05, 11:14 pm] Zia Kims: JOA SCORE = 1+2+3+2+1+2+1+0 = 12
[15/05, 11:30 pm] +91 94914 18555: Operative treatment provides excellent results for patients with severe clinical presentation (JOA score ≤7), while individuals with mild to moderate spinal stenosis (JOA score >7) should receive conservative treatment.
[15/05, 11:30 pm] +91 94914 18555: https://jorthoptraumatol.springeropen.com/articles/10.1007/s10195-005-0099-0
[15/05, 11:30 pm] +91 94914 18555: That’s more than 7 so we should technically continue conservative treatment. But what can we do now that the patient is not responding to physiotherapy or medications?
[15/05, 11:33 pm] Kshitij Kims: Well! For that we have to find out the number of physiotherapy session the pt had...! Was he adherent to its schedule?
[15/05, 11:34 pm] Zia Kims: Yes
[15/05, 11:34 pm] Zia Kims: Normally it takes around 5-6 sessions to know whether the individual is responding or not
[15/05, 11:35 pm] Kshitij Kims: Atleast! Right?
[15/05, 11:35 pm] Zia Kims: Yes
[15/05, 11:36 pm] Kshitij Kims: Asking the pt attender for that!
[16/05, 5:40 am] Akhil Kims: He used to drive for around 3 to 4 hrs in a day with small breaks in between
[16/05, 9:58 am] Shivang Sharma: Everyday habits may lead to spondylosis | Deccan Herald https://www.deccanherald.com/content/643093/everyday-habits-may-lead-spondylosis.html
Download DH App to get Latest and Personalised news
[16/05, 9:59 am] Shivang Sharma: A sedentary lifestyle can make you age faster, causing multiple aches and pains in your body. Some of you might be experiencing spondylosis, the result of constant wear and tear on the vertebrae and cartilage of the spine. If you wake up with a stiff neck or back or experience pain that is worse in the morning and at night, this is definitely a sign of spondylosis or degeneration of the inter-vertebral disc that protects our spine and facet joint.
https://www.deccanherald.com/content/643093/everyday-habits-may-lead-spondylosis.html
Lumbar spondylosis is a complicated diagnosis. We choose to define it broadly as degenerative condition of the spine, but definitions vary widely within the literature. While it may not present a challenge to identify radiographically,it pervasiveness through out all patient population makes the exact diagnosis of the symptomatic cases extremely difficult. Moreover, there is no current concrete ,gold standard treatment approach to diverse range of Patient presentation despite substantial research efforts to identify conservative and more invasive methods of managing symptoms and slowing progressive decline. Given the morbidity of low back pain within the population and its social and economic implications, this area will continue to be critical research focus.Important clues are in place, from genetic studies risk factors analysis and explorative treatment approaches .These efforts, and future endeavors will no doubt fine tune and present means to tackle not only symptoms, but confront progression and ultimately prevention of disease in years to come.
CASE: Recently I encountered an old patient of 73 year old male with chief complaints of decreased urine output since 1 month,swelling of legs and shortness of breath since3 days.
On further inquiries,he was apparently asymptomatic 1 month back and then developed decreased urine output which is insidious in onset gradually progressive amber color non foul smelling not associated with pus and blood in the urine and not associated with burning micturition.
h/o swelling of legs since 1 month which is insidious in onset and gradually progressive pitting type present in both the legs from foot till ankle.
h/o shortness of breath since 3 days which is insidious in onset gradually progressive from grade 3 mMRC to grade 3 mMRC not associated with postural and diurnal variation
no h/o chest pain, orthopnea, paroxysmal nocturnal dyspnea, sweating, palpitations.
h/o fever since 1 day which is insidious in onset gradually progressive with evening rise of temperature, not associate with chills and rigor.
no h/o blurring of vision, dizziness, paraesthesias, limbs weakness, facial weakness
Seeking into his past history, No h/o similar complaints in the past,h/o hypertension since 10 yrs and no h/o diabetes, asthma, tb, cad, thyroid disorders in the past
Sometimes personal history will directly will help to diagnose, the patient reply for personal history after inquiring was , he'll have mixed diet,apetite was normal with adequate sleep and bowel and bladder movements are regularh/o alcohol intake 150 ml per wk for 30 yrs,h/o smoking 10 ciggaretes per day for 30 yrs.
No familial history.
The provisional diagnosis according to the given information could be renal failure, urinary tract infection, urinary strictures,hydronephrosis,renal caliculi,urinary bladder caliculi.
https://shivangsharmarollno145.blogspot.com/2023/04/73-yr-old-with-decreased-urine-output.html
After the abdomen , cardiovascular, respiratory and nervous system examination hewas diagnosed with chronic kidney disease.
Chronic kidney disease (CKD)—or chronic renal failure (CRF), as it was historically termed—is a term that encompasses all degrees of decreased kidney function, from damaged–at risk through mild, moderate, and severe chronic kidney failure. CKD is a worldwide public health problem. In the United States, there is a rising incidence and prevalence of kidney failure, with poor outcomes and high cost .
CKD is more prevalent in the elderly population Almost half of the patients with CKD are older than 70 years. However, while younger patients with CKD typically experience progressive loss of kidney function, 30% of patients over 65 years of age with CKD have stable disease.
Refer:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4119330/
CASE: this case is one of the interesting case , which i encountered in my med journey.
He was 48 yr old male , Mason by occupation, came with chief complaints of shortness of breath since one week and decreased urine output since 1 week.
Since this was a sudden onset of symptoms, I eagerly started further inquiry, seeking into his all histories of illness . The patient was cooperative, though I felt a bit difficult because of language barrier, but was able to manage because of his guardian who came with him.
The patient was apparently asymptomatic 1week back .Then he developed shortness of breath during climbing stares and even walking at normal pace ( grade 2) , which gradually prdiet ogressed even at rest and last one week ( grade 4) . It was aggravated by doing work and by lying horizontally on bed and relieved by taking rest in reclined position .
There is history of gradual decreased urine output since 1 week which is not associated with increased frequency, urgency or incontinence.
No H/O fever, chronic cough, weight loss, hemoptysis, sputum,No H/O chest pain, sweating, palpitations, syncope ,No H/O burning micturition, difficulty in micturition.
With curiosity, the further past history insights show,No similar complaints in past,
history of pedal edema on and off since 1 year, present upto level of ankle,
he is a known case of hypertension since 1 year and he takes telmesartan 40mg every day morning after breakfast
No H/O diabetes, asthma, tuberculosis, epilepsy.
His personal history tells that he'd mixed diet ,normal appetite, adequate sleep with regular bowel and bladder movements.Addiction included drinking 90ml alcohol regularly since 30 to 35 years
Smoke bd daily 6/7 since last 30 to 35 years
Now he is an occasional drinker and smoker
Not similar complaints of familial history .Since last 4 years he is taking analgesics for knee pains. He took them occasionally in the beginning , but since last 2 years he took them daily or on alternate days.Since last 1 year he is taking telmesartan 40 mg every day morning for hypertension.
https://shivangsharmarollno145.blogspot.com/2023/03/1801006158-long-case.html
Further investigations are on systemic parts which revealed,
On inspection of respiratory system, everything came normal but there was scar of approximately 2 to 3 cm onthe right side of front of chest .similarly lesions are present on back of chest.No local rise in temperature And no tenderness of chest .No percussion tenderness. On auscultation everything came normal.wheeze is audible right and left inflammatory area.
On CVS examination reveals no precordial bulge,khyphoscoliosis,no visible veins and sinuses . No parasternal heaves ,percordial thrills on palpitations. on percussion, the patient left heart border is shifted laterally and right heart border is present retrosternally. No abnormal sounds on auscultation.
CNS and abdominal examination came normal.
The provisional diagnosis from the above information could be heart failure with hypertension.
Further investigations were done finally diagnosed as left heart failure with chronic kidney failure.
These investigations and his history of illness took me with a lot of questions, epidemiology of this disease?. Why chronic kidney disease is interdependent with a lot of other diseases,since it is also dependent on diabetes, and also it's further complications with heart failure???.
I referred to few research publications and pdfs:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9376857/
1-s2.0-S0085253819302765-main.pdf
CKD is common and an important independent predictor of death and hospitalization in adults with HF across the spectrum of left ventricular systolic function. Our study highlights the need to develop new and effective interventions for the growing number of Patient with HF complicated CKD.
CASE : This is case was taken during my initial year of medical school. This was my first CNS case . Looking into insights of CNS problems we come through very complicated cases.
The 18 year old boy with chief complaints of involuntary movements of both upper and lower limbs was apparently asymptomatic 1 day ago , then he developed involuntary movements ,in both upper and lower limbs, which was sudden in onset , associated with shivering,and fever.
He complained of nausea and pain after dinner in the epigastrium which was radiating towards right Iliac fossa and was pricking type with no aggravating and releiving factors.
There was also history of Shortness of breath 1 hr after playing.
At 11.30 pm he was studying, then was feeling uneasy after which he developed involuntary movements of both limbs.
No history of post -ictal confusion, uprolling of eyeballs tongue bite, involuntary defecation, micturition.
Seeking into past history no history of HYPERTENSION,DIABETES MELLITUS ,ASTHMA, EPILEPSY, TUBERCULOSIS.
Personal history was properly maintained with mixed diet,normal appetite, adequate sleep of 8hrs with regular bowel and bladder movements.
No significant family history.
https://shivangsharmarollno145.blogspot.com/2022/11/this-is-online-e-log-book-to-discuss.html
General examination followed by systemic examination was done.
On CVSexamination S1,S2 heard,no murmurs
On respiratory system examination reveals trachea central in position.
Normal vesicular breath sounds heard
BAE ++
☆CNS EXAMINATION:
●CRANIAL NERVES: INTACT
•Power
Rt UL-5/5. Lt UL-5/5
Rt LL-5/5. Lt LL-5/5
•Tone-
Rt UL -N,Lt UL-N
Rt LL-N,Lt LL-N
•Reflexes:. RIGHT LEFT
Biceps ++ ++
Triceps ++ ++
Supinator ++ ++
Knee. ++ ++
Ankle. ++ ++
Plantar:. Flexion Flexion
•SENSORY
crude touch N N
Pain N N
Temperature N N
Fine touch N N
Vibration Right Left
Upper limb. 15 sec 15 sec
Lower limb. 11 sec 10sec
Tibia 14 sec 14sec
Toe 15sec 15sec
Finger nose co-ordination :+
On abdominal examination Revealed no scars,proper bowel sounds heard and on palpitations found soft and non tender.
Since those were my initial days of med school, I was enthusiastic and was eager to learn all about seizures in various research websites, pdfs .
Few websites not only gave knowledge for only that period of time,I further used for various refrence purposes in other diseases.
With all myths surrounding medicines and medical education on television, this blog sites are an excellent opportunity to explain truth .
Reference:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4448698/
https://journals.sagepub.com/home/epi
From this case study , I learnt that seizures are 2nd most common Neurological condition after headaches. All physicians encounter patients who have seizures and may be called on to treat them.Therfore basic knowledge of seizures types,causes and treatment strategies is useful.
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