My experiences with general cellular and neural cellular pathology in a case based blended learning ecosystem's [ CBBLE ]
Namasthe,
This is Sai Pujitha Bejawada , a medical undergraduate studying in India.I'd like to share some of the interesting cases that helped me to learn more about medicine.
I'd also like to thank my seniors and my professors for guiding, teaching me, enhancing my respect for the art of medicine and finally make me better as a person.
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.
Introduction:
Being a doctor is a noble profession that goes beyond treating physical ailments. The true measure of a doctor's achievement lies in their ability to improve the quality of life for their patients and bring a smile to their faces.
As I entered the bustling general medicine ward, my eyes scanned the room, searching for a patient who stood out from the rest. And there she was, lying in a bed, surrounded by the constant hum of medical equipment. The atmosphere was charged with a sense of urgency, and I knew this case would be anything but ordinary.
Approaching the patient, I observed her pale complexion and noticed the sheen of sweat on her forehead. Her eyes, once vibrant, were now dulled by the burden of illness. She recounted her journey to this point, starting from a time when she was seemingly healthy and unsuspecting.
Five days ago, a fever had gripped her, accompanied by chilling shivers .
But the fever was not alone in tormenting her. Over the course of the next two days, she had experienced episodes of vomiting, non-bloody but persistent. The bouts of sickness brought temporary respite, a fleeting moment of relief amidst the relentless assault on her well-being.
In search of answers and relief, she had sought medical help at a local hospital, hoping for a reprieve from her worsening symptoms. It was there that she was diagnosed with dengue fever, a diagnosis that brought a glimmer of hope. Two bottles of saline were administered, an attempt to restore balance within her ravaged body. However, the fever refused to abate, holding her captive within its grip.
Frustrated and desperate, she was transferred to the city hospital, where a team of medical professionals awaited her arrival. Tests were promptly ordered, and the results were met with concern. Her platelet count stood at a mere 37,000, a dangerously low number that threatened her fragile state.
As if the physical torment was not enough, the patient had also begun to experience involuntary movements in her limbs. Both her upper and lower extremities exhibited jerky motions, a disconcerting dance of restlessness that betrayed her internal struggle. Her once calm and composed demeanor had transformed into one of agitation and diminished speech.
And so, standing at the precipice of uncertainty, I vowed to delve deeper into this enigmatic case. The cinematic scene played out before me, each moment rife with tension and anticipation. With determination etched into my every move, I prepared myself to unravel the underlying truth behind her symptoms, hoping to restore her to health and bring an end to her silent suffering.
CASE :
As I entered the busy casualty department, I was met with a patient who seemed to be in considerable distress. The chief complaints brought her to seek medical attention: pain in the left side of her face persisting for the past three days, along with episodes of vomiting that had started a day ago.
Listening attentively, I probed further into the history of her presenting illness. Just three days prior, she had been enjoying an asymptomatic period when suddenly, a throbbing pain erupted in a tooth on the left side of her jaw. The pain quickly spread, causing swelling that extended from her eyelids to below her ear. This rapidly developing facial swelling was a cause for concern.
Adding to her discomfort, she began experiencing episodes of vomiting that had persisted for the past day. Describing these episodes, she noted that they were non-projectile, non-bilious, and watery in nature, often containing food particles. There was no evidence of blood in her vomit, but the frequency of these episodes, around 6 to 7 in a day, left her feeling drained.
In addition to the facial pain and vomiting, she also reported the onset of a high-grade fever one day ago. Interestingly, the fever was not associated with chills or rigors and seemed to respond to medication, providing temporary relief.
Digging deeper into her medical history, I discovered that she had been suffering from bilateral knee pain and right shoulder pain for the past twelve years. She attributed these chronic pains to her history of non-steroidal anti-inflammatory drug (NSAID) abuse. The extent of her pain had taken a toll on her daily life, and she had resorted to overusing NSAIDs for relief.
Exploring further, I inquired about other symptoms that may be relevant to her condition. However, she denied experiencing any abdominal pain, chest pain, palpitations, burning micturition, headache, or shortness of breath.
Reviewing her past medical records, it became evident that she had not encountered similar complaints in the past. She had no known history of hypertension, diabetes, epilepsy, asthma, tuberculosis, or thyroid diseases.
As I delved into her personal history, a clearer picture of her lifestyle emerged. Her diet was mixed, her sleep was adequate, and she had a normal appetite. Bowel and bladder movements were regular, indicating no major digestive or urinary concerns. She reported occasional smoking as her only addiction, raising the possibility of a nicotine-related impact on her health.
With this comprehensive understanding of her case, I stood at the threshold of uncertainty. It was clear that her symptoms required immediate attention, and I resolved to delve deeper into the possible underlying causes. Armed with this knowledge, I embarked on a journey to uncover the answers that would provide her relief from the relentless pain, vomiting, and fever.
Case link - https://saipujithabejawada139.blogspot.com/2023/03/55yr-old-female-with-acute-kidney-injury.html
As I reviewed the laboratory results. The analysis revealed a potassium level of 2.8, falling below the normal range. This abnormality, known as hypokalemia, hinted at potential disruptions in the delicate balance of electrolytes within her body.
Further examination of her bloodwork brought attention to her serum creatinine level, which stood at 1.4. While within the normal range, this value hinted at the functioning of her kidneys and prompted a closer evaluation of renal health.
Compounding the complexity of her condition, her hemoglobin level was found to be low. This discovery, often indicative of anemia, raised questions about the adequacy of her red blood cell count and the potential impact on oxygen-carrying capacity.
PJAR DISCUSSION :
[27/03/23, 8:15:14 AM] 55F Left Buccal abscess AKI recent Telengana PaJR: Messages and calls are end-to-end encrypted. No one outside of this chat, not even WhatsApp, can read or listen to them.
[27/03/23, 8:15:14 AM] 55F Left Buccal abscess AKI recent Telengana PaJR: You created group “55/F With AKI”
[27/03/23, 8:17:32 AM] Ankitha Reddy: https://67ankithareddy.blogspot.com/2023/03/55yr-old-female-with-acute-kidney-injury.html?m=1
[28/03/23, 12:42:32 PM] Ankitha Reddy: <attached: 00000014-PHOTO-2023-03-28-12-42-31.jpg>
[29/03/23, 8:55:48 AM] Sudhamshi Kims: Prathyusha Kims added Sudhamshi Kims
[30/03/23, 9:40:15 AM] Sudhamshi Kims: 30/03/23
Admission date: 25/03/23
AMC
1 Fever spike today morning
No C/o vomitings
C/o pain abdomen subsided
Passed stools today
C/o pain in both knees and B/L hip joint
Pain and swelling over left side of face-reduced
O
Pt is conscious , coherent , cooperative
BP-120/70mmhg
PR- 90bpm
Temp- 99.8F
RR-16 cpm
GRBS- 143mg/dl
CVS- S1,S2 heard, no murmurs
RS- BAE (+), NVBS(+)
P/A-soft, non tender , no organomegaly
Bowel sounds(+)
CNS: NAD
A
Non oliguric Acute Kidney Injury(resolved) secondary to Sepsis with Left Buccal space abscess with S/P Incision and drainage with osteoarthritis of B/L hip and knee.
P
1. IVF 1 unit NS 1unit RL @ 75ml/hr
2. (D6) Inj. Monocef 1gm IV/BD
3. Inj NEOMOL 1gm IV / SOS (ifTemp >101F)
4. Inj. ZOFER 4gm IV/SOS
5.(D6) Inj. Metrogyl 500mg IV/TID
6.Inj TRAMADOL 1AMP in 100ml NS/IV/TID
7.Tab XYKA 1gm /PO/BD
8.Tab PANTOPRAZOLE 40mg PO/OD
9.Tab CHYMORAL FORTE PO/TID
10.Cap VITAMIN D3 PO/ once a week
https://67ankithareddy.blogspot.com/2023/03/55yr-old-female-with-acute-kidney-injury.html?m=1
[30/03/23, 9:40:27 AM] Sudhamshi Kims: <attached: 00000017-PHOTO-2023-03-30-09-40-27.jpg>
[30/03/23, 9:43:51 AM] Rakesh Biswas Sir: Can't see today morning's fever spike
[30/03/23, 9:44:56 AM] Rakesh Biswas Sir: Can we have serial images of her left periorbital region since admission?
Any radiological image of the abscess?
[30/03/23, 9:48:37 AM] Rakesh Biswas Sir: Rakesh Biswas Sir changed the subject to “55F Left Buccal abscess AKI recent Telengana PaJR”
[30/03/23, 9:55:31 AM] ~ Navya Lakkakula: ~ Navya Lakkakula joined using this group's invite link
[30/03/23, 9:47:07 AM] Rakesh Biswas Sir: You made me google XyKa
[30/03/23, 9:47:46 AM] Rakesh Biswas Sir: Your title is very inadequate to describe this patient
[30/03/23, 9:51:37 AM] Rakesh Biswas Sir: Project: Sepsis, predictors of outcomes # @navya
[3/30, 9:40 AM] 2017 intern : 30/03/23
Admission date: 25/03/23
AMC
Unit-6
1 Fever spike today morning
No C/o vomitings
C/o pain abdomen subsided
Passed stools today
C/o pain in both knees and B/L hip joint
Pain and swelling over left side of face-reduced
O
Pt is conscious , coherent , cooperative
BP-120/70mmhg
PR- 90bpm
Temp- 99.8F
RR-16 cpm
GRBS- 143mg/dl
CVS- S1,S2 heard, no murmurs
RS- BAE (+), NVBS(+)
P/A-soft, non tender , no organomegaly
Bowel sounds(+)
CNS: NAD
A
Non oliguric Acute Kidney Injury(resolved) secondary to Sepsis with Left Buccal space abscess with S/P Incision and drainage with osteoarthritis of B/L hip and knee.
P
1. IVF 1 unit NS 1unit RL @ 75ml/hr
2. (D6) Inj. Monocef 1gm IV/BD
3. Inj NEOMOL 1gm IV / SOS (ifTemp >101F)
4. Inj. ZOFER 4gm IV/SOS
5.(D6) Inj. Metrogyl 500mg IV/TID
6.Inj TRAMADOL 1AMP in 100ml NS/IV/TID
7.Tab XYKA 1gm /PO/BD
8.Tab PANTOPRAZOLE 40mg PO/OD
9.Tab CHYMORAL FORTE PO/TID
10.Cap VITAMIN D3 PO/ once a week
[3/30, 9:43 AM] Rakesh Biswas: Can't see today morning's fever spike
DISCUSSION :
My questions regarding this case -
- How does sepsis contribute to the development of acute kidney..?
- How might the patient's history of NSAID abuse and chronic pain contribute to the development of acute kidney injury?
- What treatment options are available for managing acute kidney injury in the context of sepsis?
- Are there any long-term consequences or complications associated with acute kidney injury in this case?
My learning :
In cases of sepsis, it can lead to acute kidney injury (AKI) through various mechanisms such as hypoperfusion, inflammation, and direct damage to renal tissue. The release of pro-inflammatory mediators during sepsis can cause injury to the kidneys and disrupt their normal functioning.
Reference link :
NSAID abuse and chronic pain can potentially contribute to the development of AKI. NSAIDs can cause kidney injury through various mechanisms, including decreased blood flow to the kidneys, direct toxic effects on renal tissue, and interference with the regulation of electrolytes and fluid balance. Chronic pain and long-term NSAID use can also lead to chronic kidney disease, which may increase the risk of AKI in certain circumstances.
Reference link - https://www.minervamedica.it/en/journals/minerva-urology-nephrology/article.php?cod=R19Y2012N01A0051
Treatment options for managing AKI in the context of sepsis include addressing the underlying infection, optimizing fluid balance, maintaining hemodynamic stability, and providing supportive care. In severe cases, renal replacement therapy (such as hemodialysis or continuous renal replacement therapy) may be necessary to support kidney function while the underlying cause is addressed.
Reference link - https://linkinghub.elsevier.com/retrieve/pii/S0140-6736(19)32563-2
Long-term consequences and complications of AKI can vary depending on the severity of the injury and the underlying cause. In some cases, AKI can lead to chronic kidney disease, which may require ongoing management and monitoring. Other complications may include electrolyte imbalances, fluid overload, and an increased risk of infection.
Reference link - https://linkinghub.elsevier.com/retrieve/pii/S0749-0704(20)30115-9
SWOT ANALYSIS :
Strengths:
1. Asymptomatic initially: The patient was apparently asymptomatic just three days ago, indicating a potential early detection of symptoms.
2. Adequate sleep and normal appetite: These factors suggest a generally healthy lifestyle.
Weaknesses:
1. Dental pain and swelling: The patient's tooth pain, swelling extending to the eyelids and below the ear, indicate a potential underlying dental or oral health issue.
2. Vomiting episodes: The patient has been experiencing multiple vomiting episodes, which can be a sign of an underlying condition or a response to pain or infection.
3. High-grade fever: The patient has a high-grade fever, indicating an active infection or inflammation.
Opportunities:
1. Diagnosis and treatment: The patient's symptoms provide an opportunity to identify the underlying cause of tooth pain, swelling, vomiting, and fever, leading to appropriate treatment.
2. Smoking cessation: Since the patient occasionally smokes, this health episode could serve as an opportunity to address smoking habits and encourage quitting.
Threats:
1. Chronic pain in the knees and right shoulder: The patient has been experiencing pain in the knees and right shoulder for 12 years, which may indicate underlying chronic conditions or potential complications.
2. History of NSAIDs abuse: The patient has a history of NSAIDs abuse, which can have adverse effects on the gastrointestinal system and may complicate the current symptoms.
REFERENCE LINKS -
2. https://www.minervamedica.it/en/journals/minerva-urology-nephrology/article.php?cod=R19Y2012N01A0051
Pujitha firstly i would like to appreciate your writing skills - nice & engaging story telling - your efforts in trying to understand and solving the patient's problem.
ReplyDeleteYour efforts and discussion around the 2nd patient was a bit more eloborative and informative but what about the 1st patient - nothing there as such except for an interesting introduction.
No proper description of course in hospital and final turn of events?
What have you learned in that patient - have you solved her problem?
Not just describing 2 or 3 patients u have to tell more about your days in the department by seeing the maximum number of cases - sharing your experience and learning points in brief.
Like what have you learned from the patient?
How did it help you and your patient?
How much can u review the literature and use it in solving their problem or not?
Finally, your learning in total and patient follow-up?
Individual patient blogs would be more impactful if you describe everything in detail - the daily routine of the patient - the sequence of events - your approach towards addressing the patient's problems - the final turn of events - the course of events in the hospital and your discussion with learning points around that particular patient at the end with proper follow up which were lacking in your blogs.
Just try to improve from next time - each and every patient is equally important and we should do our best to solve their problems.