Thursday, 19 January 2017

67F with Anaemia, HTN, venous ulcer, and multiple metabolic problems

Disclaimer:-

This is a HIPAA de-identified open-online-patient-record with initial information in patient's voice, posted here december 2016 after collecting informed patient consent (form downloadable here) by BMJ Elective Student.

As said by relatives,

In 2012, mid june she complained of extreme weekness. She consulted her family doctor, He checked on CBC and found Hb to be extremely low (6.5). He advised her to visit a bigger hospital.

We admitted her to higher center in delhi. Dr. prescribed us to transfuse 5 units of blood and aditional medication. She was there for a month and things became normal. She went back to Bengal. However, the prescribed oral medication of blood pressure and other suppliments continued.

Aunt again travelled to Delhi to attend a family function in 2013. She again felt unwell and was readmitted.

A biopsy was done under the consultation of Oncologist to check why the blood is not generated. The outcome of test was negative and this eradicated any fear of blood cancer but was advised to see a Nephrologist. She was there for half a month and brought to normalcy, however medication continued. She was prescribed Epofer 4000 injection for blood support.

4. As advised by our family doctor Dr. Anjan Dey (Delhi) we took her to Medanta Medicity for a check up under Nephrologist Dr. Ritesh Sharma. He checked on Blood reports and past records and prescribed medicines and asked for regural visits.

However, Aunt had urgent work in Bengal and she went back (she was the Head Mistress of ... School). She consulted local doctors and continued earlier medicines.

In 2014 unfortunately my uncle Mr... became seriously ill and expired due to multiple orgaon failure in Delhi and due to which we could not focus much on aunt.

In 2015-16 she developed Venous Ulcer in both her legs (lower limb) and consulted local doctor. This became acute by the end of 2016 and on mid. Dec she complained of acute respiratory disorder, low urine outcome and high fever. She was admitted in Hospital(General Physician).

2 days later, I rushed and with doctor's advise, I took her to bigger Hospital, and admitted under Nephrologist.

She was there for more than 20 days and discharged after situation came to normalcy. But she continued urinal problem.

Once back in home I opted for a blood test where I found creatinine to be 3.9 and Urea to be 276. She had fever, lack of appetite and pain in stomach. I guessed there could also be a possibility of urilogical disorder so we brought her again to hospital.

- Investigations done in the current hospital (mentioned in the narrative above)

URINE FOR COMPLETE TEST (routine + microscopic)/ URINE R/M - ]

Parameter Value Unit
PHYSICAL EXAMINATION

CHEMICAL EXAINATION
MICROSCOPIC EXAMINATION
Parameter Value Unit
PUS CELL Plenty
EPITHELIAL CELL 2 - 3
RBCs 2 - 3
CAST Granular
CRYSTAL Nil
BACTERIA Present (+)
OTHERS

Urine Culture & Sensitivity Culture Report -
Microscopy URINE FOR CULTURE AND SENSITIVITY Mixed growth, more than three types of colonies grown. Kindly repeat the sample if symptoms persist clinically, ensuring proper collection and transport

CBC-COMPLETE BLOOD COUNT - RC WHOLE BLOOD

Parameter Value Unit
HEMOGLOBIN 10.1 g/dL
TOTAL WBC COUNT 6900 cells/cumm
TOTAL RBC COUNT 3.14 millions/cu mm
PCV 29.7 %
PLATELETS 0.90 lakh/mm3

Parameter Value Unit
NEUTROPHIL 53 %
LYMPHOCYTE 26 %
EOSINOPHIL 18 %
MONOCYTE 03 %
BASOPHIL 00

Parameter Value Unit
MCV 94.6 fl
MCH 32.2 pg
MCHC 34.0 %

LIVER PROFILE ( LFT ) (T.BIL+OT+PT+ALP+PRO+ALB+GLOB+A/G RATIO) -

TOTAL BILIRUBIN 0.7 mg/dl
DIRECT BILIRUBIN 0.3 mg/dl
INDIRECT BILIRUBIN 0.4 mg/dl
SGOT 154 U/L
SGPT 103 U/L
GGT 578 U/L
ALP 322 U/L
TOTAL PROTEIN 8.7 g/dL
ALBUMIN 3.0 g/dL
GLOBULIN 5.7 g/dL

UREA & CREATININE - RC SERUM
Parameter Value Unit
UREA 311 mg/dl
CREATININE 6.1 mg/dl

HbA1C 6.3 % 4.0-6.0 RC Blood Trend Chart
BUN (BLOOD UREA NITROGEN) 145.3 mg/dl 7.0-18.6

9 days later

UREA & CREATININE - RC SERUM

Parameter Value Unit
UREA 69 mg/dl
CREATININE 1.7 mg/dl

CBC-COMPLETE BLOOD COUNT - RC WHOLE BLOOD

Parameter Value Unit
HEMOGLOBIN 6.7 g/dL
TOTAL WBC COUNT 2900 cells/cumm
TOTAL RBC COUNT 2.07 millions/cu mm
PCV 20.0 %
PLATELETS 0.9 lakh/mm3

IRON STUDIES (TIBC) - RC SERUM

SERUM IRON 64 ug/dl
SERUM TIBC 201 ug/dL
TRANSFERRIN SATURATION 31.8 %
SERUM FERRITIN > 1650.0 ng/ml

URINE FOR COMPLETE TEST (routine + microscopic)/ URINE R/M - RC URINE

Parameter Value Unit
PHYSICAL EXAMINATION
CHEMICAL EXAINATION
MICROSCOPIC EXAMINATION
Parameter Value Unit
PUS CELL Plenty
EPITHELIAL CELL 4 - 5
RBCs 7 - 8
CAST Granular
CRYSTAL Nil
BACTERIA Present (+)
OTHERS Nil

Thursday, 5 January 2017

BMJ Case Reports Student Electives - Story

BMJ Case Reports Student Electives

Patient centered learning

a journey of a thousand miles begins with a single step

A New World

- - - -

Getting opportunity to learn from Dr. Rakesh Biswas Sir is a life changer for me, while being very basic stage of learning medicine, i got to see various aspects of healthcare services and challenges. Watching various procedures and learning about them were like adventures and identifying uniqueness in common health problems and simplifying to understand them became skills that i learned from sir and will try to develop in my lifetime.

“

Changing game from Traditional Medical Education to Evidence Based Medical Education.

-Rakesh Biswas

”

3 Weeks As Elective

- - - -

With sunshine in morning i get ready to visit hospital and also check mails, messages, and facebook which we use to communicate and discuss everything.

At 9 am day start with visit to ICU with sir and see updates and find out etiology as well as progress of patient. While taking notes for online records of patients that can be discussed and utilised for better outcomes for patient health, i also have to take notes of tests and procedures to be performed so i can get a chance to observe and learn. After ICU rounds with sir, we visit SICU, Male Medicine Ward, and Female Medicine ward where i get to learn about less serious patients, examinations, and those patients who recovered from ICU and getting better. Then we visit OPD to see new and follow up cases, and check them and hear their story in detail, going back to childhood or problems long long ago, and most of times while investigating deeper, patient’s story itself opens clues for disease, its progress etc.

Lunch time - It’s great time to interact with other students and have some talk about fun topics and patients they had seen earlier or following now.

After lunch i go back to O.P.D. to see few more patients and learn, for whole day sir keep feeding me with great points, experiences, disease conditions, importance of patient’s story, and all with live examples in front. Sir also give me motivation and tells about how various students reported cases, made studies and helped medical science by gaining and sharing knowledge. Sometimes we also discuss about limitations and problems in medicine and innovations needed for to solve.

I always tried to give maximum inputs because these are only few days where i can add to my mindset and progress to learn better. I always loved and enjoyed to be with sir, he is very calm, always helpful, and also very motivating to support any innovations i plan and present to him.

During course i tried to make a simple, low cost design of beds for patients suffering from bedsores, and implemented some basic technology to make out more learning possibility in future by my efforts here.

Finally after OPD i get refreshment and start with getting some patients stories, i spend plenty of time to sit, talk, calm patient’s caretakers, and listen their story, ask relevant questions and go deeper to investigate like i saw sir, and also get a consent form signed after explaining them everything. I always keep in mind to not make any false hopes or hurt in any way.

Then at end of day i take a round to all wards and give updates to sir about each patient’s and return hostel.

At hostel i take dinner, entertain sometime on laptop, write and test few ideas that came to my mind that day and then start updating patient’s records on my online portfolio, and it give immense pleasure to see my records getting discussed by great doctors to make better outcomes for patients and helping them.

In end i would like to add that Medical science is about sharing knowledge and information. Patients Data and Story is very valuable and not only for doctors but also every student and artificial intelligent machines which gonna be reality in near future. Evidences are the way to practice medicine, and innovations are need of time. We need more innovators and will to challenge our self not only by medical knowledge but technology also to make solutions and help patients better.

I am always struggling to get educational opportunity and extremely happy to be here, also being self motivated i try to invest every second possible in learning and wish to always follow good things and concepts i learnt from sir. I also pray god and sir to give me blessings that i can cure better, making minimum mistakes and in do best in future.

Thanking you Dr. Rakesh Biswas sir for giving me opportunity enlightening me for a better future.

Wednesday, 4 January 2017

Integrating Cases in Biohack.in

http://biohack.in/1/

A case from my BMJ elective course was added on biohack.in and discussion on that case was copied from an online forum (tabula rassa in this case) and presented in google docs which have explore feature to help Artificial Intelligence for research and then on this whole info facebook comments were enabled to let other discuss and solve challenges and also learn from available data.

Healthy Eating plate for everyone

Sunday, 1 January 2017

severe Obesity, SOB and talking in sleep

Disclaimer:-

This is a de-identified open-online-patient-record with initial information in patient's voice, posted here december 2016 after collecting informed patient consent (form downloadable here) by BMJ Elective Student.

5 years ago I was diagnosed with diabetes type 2. I am 59 year old and I was married at the age of 23 after one year I had flight to weight gain and i delivered my 1st child. After 8 year again gain weight and delivered 2nd child. Though i gained weight my child was under weight, and he was not premature.

After that i gained lots of weight but never sudden increase or decrease, it just continously kept on increasing. Now my BMI is 40+ . recently after starting diabetes medication i again gained weight of around 8-9 kg in 20 days. I was 88-89 and in 20 days i became 97.

5 year ago, i had cataract surgery in both eyes at 1 month interval and i was then at same time diagnosed as diabetic. My vision is very good now.

I decreased sweet and sugar intake in last 20 days, but other food habbits are same, and also i eat very less. My urination is normal. Since 10-15 days i am finding difficulty in breathing. My life style is not very active. Since 10-15 years i have habbit of snoring in sleep and occasionally talking in sleep in very low voice. But now since 10-15 days i am also snoring loudly and talking a lot in sleep in very high voice (volume) as my family say.

Recently in 10-15 days i also got lots of mouth ulcers also and feeling that right side of face is swelled up.

Now along with respiratory problem, very loud snoring and talking in sleep, mouth ulcer, obesity and every time i take medicine, required insulin and food still having hypoglycemia even after food.

-----------------------------------------------------

Her HbA1C was within normal.

ENT evaluation - mallampatti grade 2 (soft palate not visible at all)

Grade 2 fatty liver changes

Rakesh BiswasRakesh and 2 others manage the membership, moderators, settings and posts for Tabula Rasa. Dr Preeti a similar patient of OSA was offered a prosthesis by one of your students a few years back. Is it still be offered at PCDS? Amy, Vasumathi would it be possible to share literature around efficacy of prosthesis toward patient outcomes in obstructive sleep apnoea?