A CASE BASED BLENDED LEARNING ECOSYSTEM'S CBBLE

MY EXPERIENCES WITH GENERAL CELLULAR AND NEURAL CELLULAR PATHOLOGY IN A CASE BASED BLENDED LEARNING ECOSYSTEM'S CBBLE 

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.  

I’m P.Manogna, Medical student from India. 

Through this blog i m thrilled to share the experience of my journey in general medicine department.

When i was first posted in general medicine i started my journey with a case of 60year old male with complaints of fever, hematuria and SOB. He was tested positive for dengue(NS1) at a local hospital.He had pleural effusion on right side where i had seen pleural tap for the first time. I wasn’t sure about many things as it was my beginning but this didn’t stop me take more cases.As back of mind i knew that through this learning process i would improve on many things.

https://penchalamanognarollno120.blogspot.com/2022/01/60-year-old-with-fever-hematuria.html

There was a patient 36 year old male, were i stunned to see the severity of jaundice he had, his body,hands and palms were also yellowish, he had similar complaints in past(2times),he had history of alcohol consumption since 20years in this patient i got to appreciate Flapping tremors(Asterixis) which I didn’t know before

Then i realised that by seeing clinically we can know many things which we haven’t learned before. 

https://penchalamanognarollno120.blogspot.com/2022/03/a-36-year-old-male-with-yellowish.html

Another case where a 50 year old male patient came with the chief complaints of 

B/L leg swelling and decrease urine output. On further asking him about his history he mentioned that he has diabetes mellitus since 15years and hypertension since 5years and was on medication since then on examination the abdomen was obese and hyper-pigmented spots were present on right side of abdomen. When the investigations were done they was elevated serum urea,creatinine and phosphorus levels and with low protein.It indicated that there was a renal dysfunction. I learned that we can also measure creatinine and protein by 24hrs method. And also due to the kidney dysfunction there is an imbalance between Oncotic and hydrostatic pressure which lead to fluid accumulation(pedal edema).He was diagnosed with acute kidney injury secondary to ?Diabetic Nephropathy. 

https://penchalamanognarollno120.blogspot.com/2022/10/a-57-year-old-with-leg-swelling.html

The captivating part of GM department was we had an opportunity to attend the patient anytime and clear our doubts. We used to have evening sessions where we had a chance to assess patient in presence of our senior colleagues and prepare a report. During one of these session i appreciated JVP in an old female.

One fine day me and my colleague went to ICU where a 20 year old female was admitted due to SOB at rest and they were many other complaints which included Pedal edema, Hyper-pigmented macules,

fever,cough,decreased urinary output,abdominal distention and loss of ability to speak and weakness.She was in utmost need of medical attention.

 I couldn’t make a detailed case report but one day while i was in rounds with HOD sir , to my surprise i had seen the patient was shifted to ward and was trying to walk.This was the point where i was astonished by the results of the medical attention paid by the department.

She was admitted for the 2nd time but with complaints of headache, vomiting and neck stiffness. This time I reviewed the patient,made a report and took help of my colleague about the first admission. She was diagnosed with SLE ( Tested positive for ANA blot test- dsDNA(+++),

Histone(++),nucleosome antigen(++),ku antigen(++),SmD1(++) ) in 1st admission. As She was taken to investigations the 2nd time,when she was admitted her 24hr urine protein,blood urea was elevated and there was decreased urine output. By which she was diagnosed with lupus nephritis.

https://penchalamanognarollno120.blogspot.com/2022/12/a-20year-old-with-headachevomiting-and.html

A case where a 70 year old male came with the complaints of B/L pedal edema(pitting type),SOB associated with orthopnea and decrease urine output(indicating kidney dysfunction). He had a history of HTN since 10years. This patient had chronic heart failure(CCF)(the heart is unable to pump blood which lead to fluid overload-lungs(B/L pleural effusion and legs(pedal edema)). I have learned that CAD is the most common cause for chronic heart failure.

https://penchalamanognarollno120.blogspot.com/2023/03/1801006126-short-case.html

Another case 45year old female came with the complaints of generalised body swelling, facial puffiness and SOB. On delving into her history she was a k/c/o DM-6years and HTN-5years. Few months back she developed pedal edema, facial puffiness progressed to anasarca, loss of appetite & generalized weakness for which she went to a local hospital in nalgonda where she was diagnosed with renal failure. She was advised hemodialysis which she refused to do so and developed the above complaints and came to our hospital. On investigations she was diagnosed with CKD and had severe anemia secondary to CKD. I have learned that due to CKD , the kidney which produces erythropoietin for synthesis of RBC is now disrupted  which  lead to anemia.

https://penchalamanognarollno120.blogspot.com/2023/04/a-45-year-old-female-with-sob.html

The Day I remember where i was posted in general medicine and the good part about the postings where we all had an equal opportunity to present a case which made postings more interesting and we could learn more about it while discussing about the case.

My case which i had to present was a case of diabetic keto acidosis, though it was a simple case, as everything is a part of learning. After the presentation we had a questionnaire session where our HOD sir explained a lot more in detail about the insulin types , how does keto acidosis occur and i was made to draw the insulin activity graph on board, i was stunned by the detailed teaching which helped me to push myself to see a lot of other cases and made me more interested in general medicine.

https://penchalamanognarollno120.blogspot.com/2022/10/a-13-year-old-with-vomiting-and.html

As we were going through our journey in general medicine department we had learned that diet,day to day life activities, how they are affected also play a important role which made us to take a detailed history. And going more farther we have started implementing it in case reports.

As time was passing by i got to see many more which involved each system-

There was a patient with pleural effusion and this patient had shortness of breath which was progressive from grade 2 to grade 3, through this i have learned to elaborate on SOB, how does it affect daily activites and more details of it. 

And they were many other cases like 

heart failure, acute pancreatitis, Anemia,SLE, chronic kidney disease(CKD),Alcoholic liver disease where i had opportunity to assess.

A patient of 55year old male with cerebro vascular accident(CVA) was admitted in our hospital.

He came with weakness of right upper and lower limb, slurred speech and deviation of mouth towards left side.

This was that time where I encountered a CVA case for the first time. This case 

has given me a opportunity to learn and practically do CNS examination in a more detailed way. In this patient investigations like MRI was done and an acute infarct in posterior limb of internal capsule has been diagnosed. This case has put me into a deep thought where i could dig more deeper into this vast subject where stroke localisation helped me get into the path.

https://penchalamanognarollno120.blogspot.com/2023/03/50-year-old-with-weakness-of-right.html

A 48 year old male resident of chityal, 

Autodriver by occupation came with Chief complaints ofAbdominal Distension,Bilateral pedal edema, Shortness of breath since 20days and Decreased urine output,Blood in stools since 3days.

He was accompanied by his wife, when i went to see this case which was on the first day of admission, i couldn’t get time to speak to the patient as they were investigations needed to be done , so i decided to go around with them for investigation like ECG,USG. In this process i started to ask and take the detailed history, his wife was complaining about his alcohol consumption,he has also received rehabilitation and didn’t consume alcohol for 1year and then started again,i could know how his condition is affecting his family also.

He was taken to endoscopy where he was diagnosed with grade 4 oesophageal varices.

From this case i could learn everything which is mentioned in textbook by only assessing him clinically.

https://penchalamanognarollno120.blogspot.com/2023/04/a-48-year-old-with-abdominal-distension.html

Recently, there was a case of lower back ache

Case of  37 year old male with lower back ache since 10months

https://penchalamanognarollno120.blogspot.com/2023/05/a-37year-old-male-with-lower-back-ache.html

The patient came to our hospital all the way from west Bengal to seek answers for his long suffering of lower back ache since 10months 

Upon asking him history, it was found out that the lower back ache was gradually progressive,non- radiating pain 

He said that he was suffering with pain which has been increasing on sitting for too long period of time,so he was unable to sit for longer duration which made a great impact on his daily life activities 

And for this pain he didn’t have any relieving factors which made it even worse 

Due to him unable to sit for long time,

in his profession as private employee in a company involved riding bike for transport of materials(2-3hrs/day) which he stopped doing since 3months, which made me more 

concerned and pushed me to take more detailed history 

He went to a local hospital where he was investigated 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 pain,

He has also attended physiotherapy and was given particular exercises to do which also made him realise that he was landing upon the same result i.e no improvement in relief of pain.

Despite of him seeking medical help since the beginning he was unable to get relief from the pain, which made it more of me leaning towards this case.

Upon this he also had 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.

He was asked further questions on his past where we found out that he was suffering with hypertension since 9months and was on medication since then 

He was also diagnosed with lumbar spondylosis when he seeked medical attention in aug 2022

I wondered if this problem lead any impact on any of the personal activities and asked further questions about it. He apparently claimed that he wasn’t experiencing any sleep disturbances and his bowel and bladder habits are regular. He was only concerned about the fact that he was unable to drive bike which played a important role in his daily activities but he stated that he is now doing work which doesn’t involve that much time of sitting(works for some time in a shop).

After listening to his history, I and my colleague

Shivang Sharma we proceeded for further examination 

On examination:

His vitals were within normal limits with a blood pressure of 120/80 mmHg,pulse rate of 86 beats per minute,respiratory rate of 16 cycles per minute and no fever

We focused on doing central nervous system, musculoskeletal skeletal and spine examination 

Here are some videos regarding the experience while doing examination 

This case is involving spine which is likely attributed to degenerative disc pathology-Lumabr spondylosis after seeing the investigations(MRI) involving L4-L5, L5-S1 

Based on the information we got from the patient and on examination the impression is that he was suffering from lumbar spondylosis and in his course in the hospital informed consent was taken to do endoscopy were we found out that he has multiple small Antral gastric ulcers ?NSAID induced

Management plan

Adviced tab Trigabantin(160mg) and

 Razo-D(40mg) which was adiviced by the gastrology 

Cinod(10mg)for hypertension 

PAJR Discssion:

[15/05/23, 10:02:12 PM] Rakesh Biswas Sir : What are the questions identified?

[15/05/23, 10:11:13 PM] ~ Kshitij Sharma: Sir

Can his Hypertension by treated by non-pharmacologic method?

His lifestyle seems like a cause for his Hypertension!

[15/05/23, 10:18:18 PM] ~ Kshitij Sharma: Postural syndrome! how long does he drives for (Distance )  and (duration) !

  Considering the roads , the aforementioned factors can play significant role

[15/05/23, 10:20:09 PM] ~ Lasya Cherukupalli: How would postural syndrome cause Hypertension in this patient?

[15/05/23, 10:26:57 PM] ~ Kshitij Sharma: Not the postural syndrome!

[15/05/23, 10:27:16 PM] ~ Kshitij Sharma: Hypertension might be a result of his lifestyle

[15/05/23, 10:27:25 PM] Shivang: It can cause lumbar spondylosis

[15/05/23, 10:28:06 PM] Shivang: Long-term, repetitive strain on your low back, whether occupational or recreational can causes lumbar spondylosis

[15/05/23, 10:36:21 PM] ~ Kshitij Sharma: https://pubmed.ncbi.nlm.nih.gov/9894438/

[15/05/23, 10:36:24 PM] ~ Kshitij Sharma: 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

[15/05/23, 10:37:15 PM] Penchala Manogna: 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?

[15/05/23, 11:01:12 PM] ~ Kshitij Sharma: Well! Let's find out the JOA SCORE for this pt. !?

[15/05/23, 11:14:12 PM] Zia Kims: JOA SCORE = 1+2+3+2+1+2+1+0 = 12

[15/05/23, 11:30:27 PM] ~ Lasya Cherukupalli: 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.

[15/05/23, 11:30:37 PM] ~ Lasya Cherukupalli: https://jorthoptraumatol.springeropen.com/articles/10.1007/s10195-005-0099-0

[15/05/23, 11:30:58 PM] ~ Lasya Cherukupalli: 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?

[15/05/23, 11:33:58 PM] ~ Kshitij Sharma: Well! For that we have to find out the number of physiotherapy session the pt had...! Was he adherent to its schedule?

[15/05/23, 11:34:13 PM] Zia Kims: Yes

[15/05/23, 11:34:59 PM] Zia Kims: Normally it takes around 5-6 sessions to know whether the individual is responding or not

[15/05/23, 11:35:15 PM] ~ Kshitij Sharma: Atleast! Right?

[15/05/23, 11:35:23 PM] Zia Kims: Yes

[16/05/23, 5:40:55 AM] Akhil Chowdary Kims: He used to drive for around 3 to 4 hrs in a day with small breaks in between

My questions regarding this case

1.Can NSAIDs be used in chronic lower back ache?

Non-steroidal anti-inflammatory drugs (NSAIDs) are widely used to treat people with low back pain, especially people with acute back pain. Short term NSAID use is also recommended for pain relief in people with chronic back pain

https://pubmed.ncbi.nlm.nih.gov/26863524/

2.In this case, the patient apparently claimed that the pain was not reduced even after going to physiotherapy 

So how will we proceed sir?

Based on 

JOA SCORE = 1+2+3+2+1+2+1+0 = 12

Lower back pain -1 

Leg pain or tingling -2

Gait -3

straight leg rasing -2

Sensory loss -1

Motor loss-2

Restrictions of daily activities -1

Bladder function - 0

Score more than 7 can be conservatively treated

3.When is surgery indicated in a chronic low back pain case?

The increasing burden of LBP presents a significant challenge to health care systems throughout the world. Its management should be overseen by primary care physicians and centred upon a holistic biopsychosocial approach of generally non‐surgical interventions. Even though spinal surgery does have a role in alleviating symptoms of radiculopathy or neurogenic claudication, or in circumstances where back pain is related to cancer, infection or gross instability, its role in the management of degenerative LBP is not supported by the studies currently available. 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10107811/

1. How common is the association of lower back pain with depression and somatisation?

Chronic low back pain (CLBP) patients often are described as "somatizers", who report multiple somatic complaints beyond back pain itself, but the nature and clinical significance of this observation is poorly understood. To clarify the characteristics, correlates and severity of somatization in CLBP, we rigorously assessed somatization symptoms in a sample of patients not selected for psychiatric or pain clinic referral. Male CLBP patients (N = 97), attending a primary care orthopaedic clinic, and matched healthy controls (N = 49), were assessed using the Diagnostic Interview Schedule III-A (DIS), Beck Depression Inventory (BDI), Hamilton Rating Scale for Depression (HRSD), McGill Pain Questionnaire (MPQ), Sickness Impact Profile (SIP), and the Pain and Impairment Relationship Scale (PAIRS). Although none of the subjects met strict DSM-III criteria for a lifetime diagnosis of Somatization Disorder, 25.8% of CLBP patients reported a lifetime history of 12 or more somatic symptoms, as compared to only 4.1% of controls. In the less symptomatic ranges, patients still generally reported more symptoms than controls, with 51.5% of patients vs. 8.2% of controls reporting 7-11 symptoms, and 22.7% vs. 87.8% of controls reporting 0-6 symptoms (p < .001). Major depression and alcohol dependence were significantly associated with increased severity of somatization (p < .05). Lower mood and increased impairment, but not pain intensity, were related to greater number of somatic complaints. Symptoms of somatization are prevalent, but not universal, in CLBP and the pattern of these symptoms is reminiscent of the "spectrum of severity" reported in other medical populations. Recognizing this spectrum of somatization may lead to better patient-treatment matching and improved clinical outcomes.

https://pubmed.ncbi.nlm.nih.gov/8008798/

Pain-related factors were significant related to depressive symptoms in CLBP patients. Our study found that CLBP patients who had pain duration of 1-5 years were at higher risk of developing depressive symptoms, which was similar to previous studies (32, 33). The reason may be that long-term low back pain has a negative impact on the patients' family, social and work activities, which can lead to more prone to depressive symptoms (33). However, in this study, the risk of depressive symptoms did not increase in CLBP patients with a duration of pain more than 5 years. One possible explanation is that as the duration of disease increases, patients may regard pain as more normative and adopt aggressive coping strategies, mitigating the negative effects of disease to physical and psychological health (34). Pain intensity was a risk factor for depressive symptoms in CLBP patients.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8793741/

SWOT analysis (Strengths, Weaknesses, Opportunities, Threats) of the patient's case:

Strengths:

Despite of not finding solution to his problem after consulting many doctors

He has been showing patience and a positive attitude towards his problem.

He has been properly taken care of himself and was being dedicated towards the process of management while stay in hospital 

Weakness:

He is unable to sit for long, for this he is unable to ride a bike, which may stop himself from doing such works which may involve income sources 

Opportunities: 

Orthopaedic referral for which he was evaluated properly and has given a chance for further management 

Role of NSAIDs in chronic lower back pain 

Threats:

Due to his progressive nature of pain it may affect the patient day to day activities and quality of life 

In the course he also has been diagnosed with multiple small antral gastric ulcers which may affect his appetite in future 

Due to his un resolving problem which he is facing he may go through episodes of agitation or depression