ॐ भूर्भवः स्वयं तत्सवितुर्वरेण्यं भर्गो देवस्य धीमहि धियो यो नः प्रचोदया

[ O Divine mother, may your pure divine light illuminate all realms (physical, mental and spiritual) of our being. Please expel any darkness from our hearts and bestow upon us the true knowledge.]

Greetings! I'm Dr. KSHITIJ SHARMA, an enthusiastic intern hailing from India. My expedition into the realm of Medical School commenced in September 2018, marking the beginning of an incredible journey.

Within the confines of this blog post, my utmost aspiration is to offer a glimpse into the profound encounters I've had with Case Base Blended Learning Ecosystems and PaJR. These transformative educational approaches have played a pivotal role in shaping my learning experience and equipping me with invaluable knowledge.

Furthermore, I'd like to add my own insights and reflections on the impact of these innovative methods.

Through this blog post, I aim to inspire fellow medical students and practitioners to embrace these innovative learning ecosystems and seize the immense opportunities they present. Together, we can pave the way for a brighter and more effective future in healthcare education.

CBBLE PAJR PARTICIPATORY LEARNING ACTION RESEARCH DISCLAIMER

NOTE: THIS IS AN ONLINE E LOGBOOK 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 A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS INTENDING TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT.

Dr. KSHITIJ SHARMA

My first interaction with a patient was when I was 3rd year MEDICAL STUDENT (MBBS).

One day , back in 2021 i was posted in GM dept. I was walking past a nephrology ward when I saw a middle-aged man looking at me. I made a calculated guess and walked towards the pt and asked him " I understand you have been diagnosed with Chronic Kidney Disease (CKD). Can you please tell me about your symptoms and how you've been managing your condition?"

Patient replied : Well sir, I've been experiencing fatigue, decreased appetite, and frequent urination. My primary care physician has been monitoring my kidney function, and I've been prescribed certain medications to control my blood pressure and manage my condition.

Then I asked the pt. Have you noticed any swelling in your legs, hands, or face? Any changes in your urine color or increased nighttime urination?

Patient replied: Yes, I've had some swelling in my legs and feet recently. Also, my urine output has increased during the night, and sometimes it appears foamy.

Then I asked , I'd like to inquire about your medical history. Have you been diagnosed with any other chronic conditions or undergone any surgeries in the past?

Patient replied: Besides CKD, I have high blood pressure, which I've been managing for several years. I haven't had any surgeries.

After further questioning about his general well being I examined the patient for any further ailments he could possibly have .

This being my first ever student patient interaction and I still remember to this day like it had happened in the very recent past…

56M WITH SOB AND PEDAL EDEMA

A 56-year-old Indian Male Farmer with Shortness of Breath and Pedal Edema

As a medical student, I encounter a new patient case during my clinical rotation. I am assigned to assess a 56-year-old Indian male farmer who presents with two primary concerns: shortness of breath (SOB) and pedal edema (swelling in the feet and ankles). Here's how the scenario unfolds from my perspective, with the patient's identity de-identified:

Patient Presentation:

I enter the ward to find the patient seated on the bed. He appears fatigued and is visibly struggling to breathe. I introduce myself and gather some initial information, and the patient informs me that he has been experiencing increasing difficulty in breathing over the past few weeks, along with swelling in his feet and ankles. He mentions that the SOB started two days ago and brought him to the hospital.

Patient History:

I begin by taking a detailed medical history from the patient. He mentions that he works as a farmer and is involved in physically demanding activities on a daily basis. The patient states that he has no history of smoking or alcohol consumption. He further reveals that he had pulmonary tuberculosis (TB) 22 years ago, for which he received six months of anti-tubercular treatment (ATT). The patient also adds that he was apparently asymptomatic two months ago but then developed pedal edema of Grade-I, which gradually progressed to Grade-II over a span of 10 days and reached Grade-III within the next 15 days.

Physical Examination:

I proceed with a comprehensive physical examination to further assess the patient's condition. I observe significant pedal edema, with visible swelling in both feet and ankles. The skin over the swollen areas appears stretched and slightly discolored. The patient's breathing is rapid and labored, with the use of accessory muscles.

Provisional Diagnosis:-

Based on the patient's symptoms, history, and physical findings, I considered several potential diagnoses. The most likely condition in this scenario is congestive heart failure (CHF) with a possible exacerbation due to the patient's history of pulmonary TB. The progression of pedal edema from Grade-I to Grade-III indicates the severity and chronicity of the condition. Other differential diagnoses could include chronic obstructive pulmonary disease (COPD) exacerbation, pulmonary edema, or CKD causing the .

To confirm the working diagnosis and identify the underlying cause, further investigations are warranted. These may include an electrocardiogram (ECG) , a chest X-ray to evaluate lung fields and blood tests such as complete blood count (CBC), renal function tests, liver function tests, and cardiac biomarkers. Additionally, a sputum culture and sensitivity test may be performed to assess for any active pulmonary infection.

Test results:-

Reticulocyte Count:- Normal

SAAG :- 1.55 (Normal range<1.1)

LDH in ascitic fluid :- Lowered

Serum LDH :- within the Normal range

Blood Urea :- Elevated -19 mg/dl ( Normal Range 12-42 mg/dl)

Urine protein levels :- +++

Urine protein/ Cretinine ratio :- 2.76 (196/70)

Hemoglobin :- 5.4 gm/dl

RBC count :- 2.34 million/cumm (Normal 4.5-5.5 million/mm^3)

Interpretation of the test results:-

1. Reticulocyte Count: Normal

- This indicates a normal level of immature red blood cells (reticulocytes) in the blood. It suggests that the bone marrow is adequately producing red blood cells.

2. SAAG (Serum-Ascites Albumin Gradient): 1.55 (Normal range <1.1)

- SAAG is used to assess the cause of ascites, which is the accumulation of fluid in the abdominal cavity. A value above 1.1 suggests the ascites is likely due to portal hypertension, commonly seen in conditions like cirrhosis. The value of 1.55 indicates a higher probability of portal hypertension as the cause of ascites.

3. LDH (Lactate Dehydrogenase) in ascitic fluid: Lowered

- LDH is an enzyme that may be measured in ascitic fluid. A lowered LDH level in the ascitic fluid may suggest a reduced cell turnover or decreased inflammation in the abdominal cavity.

4. Serum LDH: Within the Normal range

- The LDH level in the serum is within the normal range, indicating no significant abnormalities or cell damage in the body.

5. Blood Urea: Elevated - 19 mg/dl (Normal Range 12-42 mg/dl)

- An elevated blood urea level may indicate impaired kidney function or other factors affecting nitrogen metabolism. However, without additional information, it is difficult to determine the exact cause or significance of this finding.

6. Urine Protein Levels: +++

- The presence of +++ indicates a high amount of protein in the urine, which may be suggestive of kidney dysfunction or other underlying conditions affecting the urinary system. Most likely Nephrotic Syndrome

7. Urine Protein/Creatinine Ratio: 2.76 (196/70)

- The urine protein/creatinine ratio is used to assess the amount of protein excreted in the urine relative to creatinine levels. A ratio above the normal range may indicate increased protein leakage into the urine, which could be indicative of kidney damage or disease.

8. Hemoglobin: 5.4 gm/dl

- Hemoglobin is a protein in red blood cells responsible for carrying oxygen. A hemoglobin level of 5.4 gm/dl is significantly below the normal range, indicating severe anemia. It suggests a decreased ability of the blood to transport oxygen to the body's tissues.

9. RBC Count: 2.34 million/cumm (Normal 4.5-5.5 million/mm^3)

- The red blood cell count is considerably below the normal range, indicating a low number of red blood cells in circulation. This finding is consistent with the low hemoglobin level and supports the diagnosis of severe anemia. Which might have been due to decreased erythropoietin secretion 2° to CKD?

Provisional Diagnosis:

Nephrotic Syndrome with Hypertension and anemia due to decreased erythropoietin secretion

Case link :- https://kshitijsharmamyrollno192case1.blogspot.com/2021/10/this-is-online-e-log-book-to-discuss.html

52M with HTN DM & LBA

As an Intern I got a chance to interact with a pt and take his case history over a phone call ( Telephonic case taking) . I had a chance to read pt. Complaints in his own word, very well described, but I still needed to talk to him to find out the more about his complaints .

The pt was middle aged gentleman, soft spoken , co-operative . While interacting with him i could understand that he was a loving father, a caring husband ,a responsible man . He seemed he was more worried about his child's problem than his own.

Coming back to case history taking.

The patient of apparently asymptomatic 7 years back then he noticed a gradual weight loss which was generalized throughout the body. he also experienced thirstiness, generalized weakness and frequently felt hungry. for this he went to the doctor and got diagnosed with diabetes type 2 for which he was prescribed METFORMIN HCL 1000 mg which he takes usually before breakfast.

8-9 months back he developed lower back pain of the left side which was shooting and radiating type till the hamstring muscles. for this he went to nearby doctor and was prescribed TAB. NEUROKIND ? which he took for about one and a half month. and he got relieved using this medication within 15 days and he completed the course of one and a half month.

6 months back he developed pain in his tailbone which aggravated on prolonged sitting. for this he got advised to use a physio pillow after using which his pain got diminished. but without the use of this pillow or sitting on hard surfaces the pain aggravates.

2 years back the patient and the people around him noticed a marked change in his facial appearance which he describes as facial muscle loss and loose facial skin. this has effected the patients self confidence and his ability to mingle with people as he was always pointed out about how his face had become less attractive and dull.

Apart from the above mentioned issues his concentration has decreased in his general office work from past 1 year.

While I asking more questions for getting to his provisional diagnosis, he told me about an his past.

Patient is TAX CONSULTANT by occupation since the year 2002. his profession requires him to sit for about 10-12hrs a day at one place. he lives away from home as his work place is in a different city.

Patient belongs to the upper middle class was married the age of 34YEARS.He has a son [ 16YEARS ]

His son got diagnosed with brain tumor at the age of 3YEARS, surgery was not indicative as the age was a contraindicatory in his case so medications were continued and a minor supportive surgery was performed. At the age of 7YEARS his son was attacked by left facial paralysis after which he was again admitted and in the year 2013 he was operated and the tumor was removed.

In the year 2021 the patients son complained of severe headache and when on the way to the hospital he felt unconscious in the ambulance. Upon examination he was diagnosed with the reoccurrence of the brain tumor and internal bleeding for which he was operated. after the operation took place whole of his left side got paralyzed which was treated with supportive PHYSIOTHERAPY. Now the patients son is able to move his limbs on the left side but still left with few restrictions in his fingers and wrist.

This scenario of his son's medical issue left the patient both FINANCIALLY and MENTALLY INVESTED. And with time it took a greater toll on his finances and emotional mental status.

He lives away from his family for work and meets them on weekends. Cooks his own food, and works for long hours . That gave me an impression that he might get MENTALLY EXHAUSTED some day.

Now I am working with pt. and my team to get to the right diagnosis.

Case blog:- https://smdziauddin203.blogspot.com/2023/05/52-years-male-with-hypertention.html

Case of a 55 year old female with LOW BACK ACHE (LBA) since 15 years

One fine morning, while assigned to the Department of Dermatology, a fellow intern reached out to me, seeking assistance in conducting a comprehensive case history of a 55-year-old female patient who had been enduring lower back ache for the past 15 years. The primary challenge in this endeavor was a language barrier. Intrigued by the complexity of the case, I was eager to delve into it and unravel a diagnosis.

Upon arriving at the ward, my attention was drawn to the patient, who appeared visibly fatigued, possibly due to an arduous journey to the hospital. In order to ascertain the patient's linguistic preferences, I respectfully inquired with her son whether she felt comfortable communicating in Hindi. To our realization, the patient did not comprehend the Hindi language. Consequently, we relied on her son as our primary source of information throughout the data gathering process.

The patient hails from Assam, and entered the institution of marriage at the tender age of 18. Four years into matrimony, she embarked on a farming career, toiling diligently in fields that demanded hours of arduous labor. Her tasks encompassed ploughing, sowing, and transplanting, necessitating prolonged periods of bending forward and leaning.

About 15 years ago, her existence seemed unmarred by health issues until a low back ache emerged, its presence growing subtly but relentlessly over time. This affliction unleashed radiating pain that coursed through both lower limbs, with a pronounced emphasis on the left side, particularly targeting the calf muscles. Accompanying this discomfort were tingling sensations and numbness, predominantly experienced on the right side. Prolonged sitting exacerbated her agony, impeding her ability to remain seated for extended periods. Furthermore, the pain intensified upon transitioning from a forward-bent stance to an upright posture, as well as during movements involving hip rotation and backward extension. Regrettably, she failed to identify any palliative measures to alleviate her suffering.

The progressive nature of her symptoms compelled her to cease her agrarian endeavors eight years ago. Seeking solace, she sought the expertise of a physician in Kolkata for her lingering low back pain. The medical practitioner administered an injection at the sacroiliac (SI) joint, bestowing temporary respite for a fleeting span of one to two months. Alas, her reprieve was ephemeral, as the pain resurfaced with similar intensity in due course.

Aside from her persistent lumbar discomfort, she has grappled with urinary urgency for a decade. Curiously, this urgency occurs devoid of the customary accompaniments of burning micturition, pain, hesitancy, or increased frequency.

Moreover, she has endured a decade-long battle with neck pain, often entangled with recurrent headaches. Seeking solace, she consulted a medical professional who prescribed medication and a series of exercises, both of which she faithfully incorporates into her daily routine. Yet, despite her unwavering commitment, her neck pain and headaches persist, offering no reprieve from their unrelenting grip.

https://tellashruthi159.blogspot.com/2023/05/ajnd-project.html?m=1

PaJR discussion

Project: Clinical complexity in patients with chronic low back ache

https://chat.whatsapp.com/IuiZ9ziiRI7INXH4YiCDxW

[4/30, 10:54 PM] Rakesh Biswas: Please elaborate on how to score our patient's joa score @⁨Kshitij 2018 Kims⁩

[4/30, 11:08 PM] Kshitij 2018 Kims: https://www.researchgate.net/figure/The-Japanese-Orthopaedic-Associations-scoring-system-JOA-Score_tbl1_268790894

[5/1, 8:52 AM] Rakesh Biswas: What is this patient's score?

5/1, 8:54 AM] Rakesh Biswas: Also please let us know by reviewing the literature, what's the best way to capture the apd spinal canal diameter and area on MRI

[5/1, 9:01 AM] 2018 Tella Shruthi Kims: Lower back pain -1

Leg pain or tingling -1

Gait -0

straight leg rasing -1

Sensory loss -2

Motor loss-2

Restrictions of daily activities -1

Bladder function -3

[5/1, 9:02 AM] Himaja Kims Med Pg 2022: What is the interpretation of score 11?

[5/1, 9:05 AM] Kshitij 2018 Kims: The score is 5! Considering mild dysuria indicates (-3)

[5/1, 9:07 AM] Himaja Kims Med Pg 2022: Score more than 7 can be conservatively treated

[5/1, 9:08 AM] Kshitij 2018 Kims: Yes ma'am! But our pt score being 5! Can't be managed just conservatively!

5/1, 9:13 AM] 2018 Tella Shruthi Kims: ma’am the patient had injection administered to her lower back 8 years ago and she only felt a relief for 1-2 months after it later she complained of similar symptoms ,also she’s on drug therapy since then …isn’t it a failed conservative management

[5/1, 9:24 AM] Rakesh Biswas: What would be a successful treatment for backache?

Is the success duration dependent (for example the 2 month success with injection) or is it possible to attain low backache nirvana from surgical interventions?

We analysed 3859 patients with Lumbar Spinal Stenosis [(LSS); mean age 66; female gender 50%] and 617 patients with Lumbar Degenerative Spondylolisthesis [(LDS); mean age 67; 72% female gender]. The accuracy of identifying 'completely recovered' and 'much better' patients was generally high, but lower for EQ-5D than for the other PROMs. For all PROMs the accuracy was lower for the change score than for the follow-up score and the percentage change score, especially among patients with low and high PROM scores at baseline. The optimal threshold for a clinically important outcome was ≤24 for ODI, ≥0.69 for EQ-5D, ≤3 for NRS leg pain, and ≤ 4 for NRS back pain, and, for the percentage change score, ≥30% for ODI, ≥40% for NRS leg pain, and ≥ 33% for NRS back pain. The estimated cut-offs were similar for LSS and for LDS.

Conclusion: For estimating a 'success' rate assessed by a PROM, we recommend using the follow-up score or the percentage change score. These scores reflected a clinically important outcome better than the change score.

https://pubmed.ncbi.nlm.nih.gov/30658613/

Can you share literature around "failed back pain surgery syndrome" as well as randomized controlled trials of trials for discectomy v placebo sham surgery?

Reviewed by Tella Shruthi

Sixty-four patients aged 25-60 years with low back pain lasting longer than 1 year and evidence of disc degeneration at L4-L5 and/or L5-S1 at radiographic examination were randomized to either lumbar fusion with posterior transpedicular screws and postoperative physiotherapy, or cognitive intervention and exercises. The cognitive intervention consisted of a lecture to give the patient an understanding that ordinary physical activity would not harm the disc and a recommendation to use the back and bend it. This was reinforced by three daily physical exercise sessions for 3 weeks. The main outcome measure was the Oswestry Disability Index.

Results: At the 1-year follow-up visit, 97% of the patients, including 6 patients who had either not attended treatment or changed groups, were examined. The Oswestry Disability Index was significantly reduced from 41 to 26 after surgery, compared with 42 to 30 after cognitive intervention and exercises. The mean difference between groups was 2.3 (-6.7 to 11.4) (P = 0.33). Improvements inback pain, use of analgesics, emotional distress, life satisfaction, and return to work were not different. Fear-avoidance beliefs and fingertip-floor distance were reduced more after nonoperative treatment, and lower limb pain was reduced more after surgery. The success rate according to an independent observer was 70% after surgery and 76% after cognitive intervention and exercises. The early complication rate in the surgical group was 18%.

https://pubmed.ncbi.nlm.nih.gov/12973134/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4501532/#:~:text=Based%20on%20antero%2Dposterior%20diameter,mm2%20are%20severely%20stenotic.

2.Patient was advised by neurosurgeon to undergo L4-L5 ,L5,S1 discectomy and laminectomy

In view of this we researched and found a clinical trial

https://pubmed.ncbi.nlm.nih.gov/12973134/

This study compared two treatments for long-term low back pain. One group received surgery, and the other group received exercises and education. After one year, both groups had improved, but the surgery group improved slightly more. However, the differences were not significant, meaning they could have happened by chance. The surgery group had more complications than the exercise group. Overall, both treatments were helpful for most patients, but surgery had more risks.

Hence we went forth with cognitive interventions consisting lumbar back support painkillers (pregabalin ,duloxetin ),pyscho education

3.JOA score to assess the need for surgery

Lower back pain -1

Leg pain or tingling -1

Gait -1

straight leg rasing -1

Sensory loss -2

Motor loss-2

Restrictions of daily activities -1

Bladder function -0

1+1+1+1+2+2+1+0=9

Score more than 7 can be conservatively treated

FAILED LEARNING POINTS

1.she has urinary hestitancy ,can it be cauda eqina syndrome ?

since cauda equina is LMN lesion it will usually present with symptoms of incontinence rather than frequency and urgency hestitancy ,beside CES is an emergency condition

2. What would be a successful treatment for backache?

Is the success duration dependent (for example the 2 month success with injection) or is it possible to attain low backache nirvana from surgical interventions?

A study compared lumbar fusion surgery with cognitive intervention and exercises in 64 patients with low back pain and evidence of disc degeneration. The main outcome measure was the Oswestry Disability Index.

https://pubmed.ncbi.nlm.nih.gov/30658613/

3.Failed back surgery syndrome (FBSS) is a term used to describe persistent or recurrent low back pain following spinal surgery. It is a complex condition that can have a significant impact on the quality of life of patients. The reasons why surgery may fail are multifactorial and can include incorrect diagnosis, inadequate surgical technique, complications during surgery, and underlying medical conditions.

4.why was our patient on sulfasalazine

if the patient is suspected to have an inflammatory condition, such as ankylosing spondylitis or psoriatic arthritis

[06/05/23, 2:45:42 PM] Tella Shruthi: spl 2 -says joa score of more than 7 should be conservatively managed and

Spl- proves that indeed there was no need for surgery since surgery vs placebo after year yielded same results

[06/05/23, 2:46:42 PM] Tella Shruthi: Slp-1 is only telling us when to call it moderately or severe lumbar canal stenosis

[30/04/23, 3:47:19 PM] Rakesh Biswas: Please share her clinical images of visceral fat and muscle mass @918790889907. Did you check @918897799393 's image links to how can get eyeball estimates of body fat?

Please share your eyeball estimate of her body fat after going through the links in Pavan's projr.

A fat muscle ratio would be great if you could share

[30/04/23, 3:56:18 PM] Himaja Gen Med Madam: To my eyeball estimation it is 35% sir

[30/04/23, 4:08:39 PM] Kshitij Sharma: Then my estimation would be 30%

[30/04/23, 10:13:26 PM] Rakesh Biswas: 30-40%?

Although again this estimation is based on eyeballing absence of muscle such as six packs in the abdomen?