Osce questions and learning points.

 8th December 2023

Osce questions:

1)  Hypertension causing chronic kidney disease vs chronic kidney disease leading to hypertension?

Chronic kidney disease (CKD) is both a common cause of hypertension and CKD is also a complication of uncontrolled hypertension. 

Ckd causing hypertension:

CKD have higher prevalence of traditional risk factors for atherosclerosis, hypertension, diabetes however additional mechanism of cardiovascular diseases may also be implicated. left ventricular hypertrophy is commonly found in patients with CKD secondary to hypertension and anaemia. Calcification of the media of blood vessels also occurs.

The pathophysiology of CKD associated hypertension is multi-factorial with different mechanisms contributing to hypertension. These pathogenic mechanisms include sodium dysregulation, increased sympathetic nervous system and alterations in renin angiotensin aldosterone system activity.

A target blood pressure of 140/90 mmHg is recommended for patients with ckd.

Hypertension causing ckd:

High blood pressure can constrict and narrow the blood vessels, which eventually damages and weakens them throughout the body, including in the kidneys. The narrowing reduces blood flow.

Kidneys no longer work properly and are not able to remove all wastes and extra fluid from your body. Extra fluid in the blood vessels can raise blood pressure even more, creating a dangerous cycle, and cause more damage leading to kidney failure.

2) At what levels of urea and creatinine diuretics can't work and dialysis is done?

Urea levels-35.7mmol/litre

Creatinine levels- 29% 

As kidneys are severely damaged the urine cannot be excreted so there is no use in taking diuretics for edema so then dialysis is recommended.

References: Davidson's textbook, https://pubmed.ncbi.nlm.nih.gov/2787322

Learning points:

* I have learnt how to differentiate between edema caused due to cardiac failure and chronic kidney disease from the basics.

* I have learnt the mechanisms behind how ckd causes hypertension and cardiac failure and how hypertension causes kidney disease.

* I have learnt the various types of access to the dialysis (central venous catheter, arteriovenous fistula, av graft) and types of av fistulas and regarding dialysis procedure 

* I have developed my communication skills and interpersonal relationship with the patient and her attenders.

76 yr old female with pedal edema.

 6th December 2023

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

I have 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 diagnosis and treatment plan.

Date of admission - 6th December 2023

A 76 year old lady home maker by occupation resident of nalgonda came to opd with chief complaints of 

Pedal edema and shortness of breath since 4 days.

Decreased urine output since 4 days.

History of present illness:

She was apparently asymptomatic 1 month back then developed loss of appetite, indigestion, nausea and vomitings since 1 month for which she was taken to hospital and found to have raised urea and creatinine levels and was suggested to get dialysis done.

she presented with bilateral pedal edema pitting type extending upto the knee since 4 days.

Shortness of breath grade(1-2) since 4 days.

No history of chest pain and palpitations.

No history of burning micturition.

Daily routine before the onset of disease:  

wakes up at 6:00 am.

Does all the household works like cooking, and cleaning utensils and tailoring work.

1-2 pm - eats lunch, sleeps after having lunch.

wakes up at around 4:00 pm does some stitching work or watches Tv.

Dinner around 8pm and sleeps after dinner.

Past history:

Known case of hypertension since 4 years and on medication clinod-t (clinidipine 10mg and telmisartan 40 mg).

Not a known case of DM, asthma, TB, epilepsy, CAD, CVD and thyroid diseases.

Personal history:

Diet :mixed 

Appetite: decreased 

Bowel and bladder movements regular 

Sleep: adequate 

No allergies and addictions 

Family history:  not significant

General examination:

Patient is conscious, coherent and cooperative.

Well oriented to time and place.

Moderately built and nourished.

Pallor- absent 

Icterus - absent 

No clubbing, cyanosis and lymphadenopathy.

Pedal edema- present 

Vitals:

Temp: 98.2 f

Bp: 120/80mm hg

PR: 88 bpm

RR: 16cpm

Systemic examination:

CVS:s1s2+,no murmur

RS:BAE+,no added sounds 

P/A: 

Inspection: Shape of abdomen- slightly distended.

Position of umbilicus: central and inverted

No scars and sinuses are present

All quadrants are moving equally with respiration

Palpation:No tenderness 

No organomegaly

Auscultation:

Bowel sounds heard 

CNS: NFD

Investigations:

ECG: 

Provisional diagnosis - chronic kidney disease on mhd.

Treatment given- 

Internal assessment 2

 

Internal assessment - July

 

Personal practical patient experience.

I'm K. Sai likhitha  a medical student from India. Here in this blog i share my personal learning experience in medicine department beginning from my first patient practical interaction. 

This elog has been created after taking the consent from the patient and their relatives. Links to some of the logged case reports are attached along with my personal patient experience and learning outcome from that particular case.

My experience with the case based blended ecosystem in medicine department has been very unique and  transitional with time. Initially when i have seen our professors and interns discussing the cases through an online call during my second year of MBBS, i was very enthusiastic and interested but I have no idea about anything at that time. After a couple of similar online calls, my eagerness and interest has started sloping down and the only thing i have learnt during that time was to get aware of most of the terminology. It was almost more than one Android half year( due to covid) after joining in the first year of MBBS i have seen something like this and it really felt like the actual medicine training is gonna start from now. And from then it took a few more months to practically see the patients personally in the wards and talk to them. 

First personal patient encounter

Link to the case: https://www.blogger.com/blog/post/edit/6532713601891436629/4849626673101142178

This is the case of a 34 year old female with recurrent vomitings since 6 months. Initially i was surprised that why does the vomiting didn't bother her at all since 6 months, eventually after seeing more patients i registered that pain is the ultimate thing that brings a person to the clinic. Many patients are concerned only when the symptoms are troubling their daily routine until then they don't want to visit the hospital. This patient even though she had vomitings since 6 months she came to hospital because the frequency of vomiting has increased and she could not perform her work due to weakness.

She was very thin built and on examination pallor was present. Her blood pressure was 110/60 mm hg. The provisional diagnosis was acute hypertension secondary to dehydration and vomitings. 

This helped me improving my history taking skills and communication with the patients. I have also learned how the dehydration due to vomitings can cause the secondary hypertension with its effects on cardiac and renal systems.

50 yr old male with fever and cough with sputum.

 

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

I have 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 diagnosis and treatment plan.

Patient came with chief complaint of cough since 

7 Days, Fever since 7 days, with difficulty in breathing since 7 days

History of presenting illness:

Fever since 7-days high grade-not associated with chills and rigor, evening rise + Associated with sweating

Cough since 7- days associated with less amount of sputum, mucoid. blood tinged aggravated on changing position from lying down to sitting position, no reliving factors

SOB grade - I MMRC -: 7 days more associated with cough, relieved on rest not associated with wheeze

NO H/O similar complaints in the past 

No past H/O TB, loss of appetite, loss of weight

K/C/O: Dm+ since 2years 

N/K/C/O HTN,CAD ,Br Asthma ,epilepsy 

H/o RTA 1 1/2 year back
Fracture of neck of femur with dynamic hip screw surgery done in outside Hospital.Immobilisation 1 month to 1-1/2 year back

- H/o -electrocution 
 4-years back - Burns both hands

PERSONAL HISTORY

Patient is Binge Alcoholic and Smokes 18 cigarettes in a day later he started smoking Bedi Suttas(high tobacco cigar) in day. 

Patient attendant said that their neighbour has TB ( who is son in law of him )

And Patient visits weekly 4 times to his home & spend with him approximately 1-hour a day

Patient started to have fever since 10 days at night time with burning sensation all over the body

Patient started to have unbearable pain at lower back  during cough .and always needed help from attendants to hold his back during coughing.

PAST HISTORY

K/c/o DM  since 2 years was diagnosed during his RTA treatment and is on regular Glimiperide 1mg &Metformin 500mg medication since then.

He has no history of  hypertension, diabetes ,asthma, epilepsy, tuberculosis.

GENERAL EXAMINATION 

Patient is conscious, cooperative ,coherent and oriented with time , place , date.
Slightly pallor, 
No icterus, cyanosis, clubbing, lymphadenopathy, edema was noted

VITALS:
Bp-80/40 mm Hg
Pr-102 bpm
Rr-25 cpm
Temperature:99.5
Spo2: 98%@RA
GRBS- HIGH

 

Sputum sample:

       

Burns in both hands: 

Slight discoloration on lower back:

Surgical implant (L) Leg scar:

SYSTEMIC EXAMINATION

CVS:S1 S2 heard , No murmurs 

CNS:

No focal neurological deficit

RS:

Breath movements -abdominal thoracic

In infra scapular area of left lung

Inspection: chest shape normal, 

Dysponea - present

Palpation: trachea -central

Auscultation: basal crepitations are heard

INVESTIGATIONS

 06.05.2023

  07.06.2023

HRCT - Findings 

                            06.06.2023

PROVISIONAL DIAGNOSIS

Fungal Ball Aspergilloma(?)

Cavitating pneumonia(?) TB (?) Uncontrolled Sugars (resolving)

TREATMENT

IV Fluids@ 75ml /hr

Inj.Neomol 1gm IV/SOS (if temp more than 101 F)

Tab.Dolo 650mg PO/TID

Syp.Grillinctus dx 2tsp PO/TID

Inj HAI S/C TID ( acc to GRBS )

Inj Augmentin 1.2gm Iv/ BID