1) Self reflective writing on their medical student career

1) Self reflective writing on their medical student career 

Hello I’m Cherish Kandru Intern from 2k18 batch.

"My bounty is as boundless as the sea, my love as deep; the more I give to thee, the more I have, for both are infinite".

Well, that was Shakespeare in his well-known play Romeo and Juliet!

This reminds me of a Medical Student's journey from being that timid scared first-year kid to becoming a full-baked Doc! That attitude of giving it more is what keeps them in the race. Be it their time, the quest for knowledge, or the patience with the patient is something that breaks the mold. It's something that allows you to change your tune.

 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

Hello there! 

This is Dr.Cherish Kandru and this is my expedition through the Medicine floor.

The Firsts!

My first experience with my patient was something that stayed with me for quite some time. She was an 18-year-old, lying on the bed in the first cubicle. I believe back then she was the youngest in the ward among others yet yoked upon with a lot. She was with her parents who seemed worried. I still remember the smile on her face. It did remind me of the age-old saying "The robbed that smiles, steals something from the thief". Well, that was life stealing her teens.  That was quite an emotional experience for me with my patient just thinking of how I take things for granted.

This girl presented with complaints of Vomitings for 5 days. As I was trying to ask about her medical history she told me that she was diagnosed with SLE a few months back. Then everything started to add up. That butterfly rash on her face and her mother telling about the pain in the little girl's joints (PIP, MCP, wrist, elbow, shoulder joints). 

On examination, she had pallor and there was bilateral pedal edema. Rest all in the systemic examination was normal. 

Later while I was checking her reports, her Hb was something around 8 gm/dl which gave me the joy that I was able to pick up the pallor, my first ever clinical finding! And then I found out that she was positive for both Anti-ds DNA and ANA.

~ Anti-ds-DNA:- It correlates with the disease activity or progression of the disease.

~ ANA:- It has got 99% sensitivity for SLE.

But it can also be seen in other conditions like Sjogren's and Scleroderma.

~ Then I also learned about the diagnostic criteria for SLE and correlated them with those present in the patient.

https://kandrucherishrollno68.blogspot.com/2022/02/have-been-given-this-case-to-solve-in.html 

And then this happened! I was posted in Medicine for a month where during my hours after college I came across this patient who was in severe pain and he was stooping forward to relieve the discomfort. The patient complained of severe abdominal pain. He gave h/o trauma over the abdomen, h/o bilious green-colored projectile foul-smelling vomiting, h/o pain radiating to the back and shoulder tip, and h/o chronic alcohol consumption. Well, the patient had a very lengthy history and this was the patient from whom I learned a lot about the importance of history taking in Medicine. The Complaint, Posture, and History ( of Vomiting, and alcohol consumption) all pointed to the provisional diagnosis of Chronic Pancreatitis. And one thing which added to my diagnosis was the Pseudocyst of the Pancreas which was the finding on CECT.

https://kandrucherishrollno68.blogspot.com/2022/02/have-been-given-this-case-to-solve-in_28.html 

A missed point and a question that changed the perspective! 

A 54-year-old woman with a history of repeated blood transfusions and here she was in our GM ward with her Hb levels somewhere around 4gm/dl. She had h/o Pulmonary Tuberculosis, Hyperthyroidism ( that explained her thin built). After taking the history as I was searching for other blogs done by my colleagues and seniors, I found something that no one else mentioned and neither the patient talked about how she was diagnosed with Rheumatoid Arthritis a few years back. And that was when it occurred to me that maybe the RA component and the recurrent anemia could be related. And as I posed this question during my presentation the next day that was when everyone found out about it( the RA) and suddenly the whole perspective of the case changed that an autoimmune component might have been causing the disease in her lungs( maybe misdiagnosed as TB) and it might also be the reason for anemia and her ARF ( well her creat levels were shooting up by then ). A single point in the patient's history that was somehow missed changed the entire perspective of the case. Well, this is something that I'm gonna remember. A single question that changed the whole stance.

https://kandrucherishrollno68.blogspot.com/2022/08/this-is-case-of-54-year-old-woman-who.html 

The DRESS Syndrome Patient.

 This was the first patient for whom I was able to palpate Hepatomegaly, Splenomegaly, and lymphadenopathy. That indeed was a Jackpot for a final year medical student that would find them only in the books until then. 

A 24 year old male who is a driver presented with complaints of Pain and Red spots on the tips, pulp, and nailbed of fingers (Rt hand) for days.

On Examination-

~Generalised Lymphadenopathy + (Enlarged and palpable cervical, axillary, Inguinal LN).

~Petechiae over the chest.

~Liver- Palpable (Hepatomegaly)

~Spleen- Palpable (Splenomegaly)

And our PaJr group discussions went on as follows-

8/17/22, 16:29 - Rakesh Biswas Sir: 24 M with fingertip pain presented to dermatology opd and brought to us. On clinical examination generalized lymphadenopathy and hepatosplenomegaly. WBC counts 44,000 with 90% eosinophils and AEC of 26000

8/17/22, 16:33 - +91 96529 55915: Yes Hypereosinophilic syndrome a likely differential here sir. Usually presents with nerve involvement.

8/17/22, 16:33 - +91 90001 66698: ABPA differential? 

8/17/22, 16:35 - Raveen Sir GM KIMS:

Right ring finger 

Tip

8/17/22, 16:35 - Raveen Sir GM Kims: He was also having 

Right MCP and PIP joint pain

8/17/22, 16:36 - Raveen Sir GM Kims: With no apparent swelling

8/17/22, 16:39 - Raveen Sir GM Kims: 4 days since the presentation he is having pain in tip of the finger on pressing the pulp of the finger 

No nodules no specific dermatome 

He has the same painful lesion in lateral aspect of right plantar side

8/17/22, 16:40 - Cherish Kandru: https://kandrucherishrollno68.blogspot.com/2022/08/25-year-old-male-who-is-resident-of.html 

8/17/22, 16:47 - +91 96529 55915: Okay. So why is the pulp tender? And also which anatomical structure in lateral aspect of right plantar surface of foot is painful?

This sounds like a nerve lesion to me and reeking of Mononeuritis Multiplex which is common with Hypereosinophilic syndrome

8/17/22, 17:01 - +91 96529 55915: So problem representation appears to be

Young man with systemic symptoms of poor appetite since a few months with involuntary weight loss and post prandial abdominal pain, which resolved in a week, now presenting with pain in a few fingertips of right hand and right lateral plantar surface.

Exam revealed Generalized LN enlargement and hepatosplenomegaly with labs showing normal lineages of RBCs and Platelets.

Problem list.

1. Pain in finger tips and plantar surface, both on right side

2. Lymphadenopathy

3. Hepatosplenomegaly

Tackling hepatosplenomegaly should be easiest and is best started with the framework of Water, cells and molecules.

Water - Portal hypertension. No other features such as dilated veins and ascites. So ruled out.

Cells - Large cells infiltrating the liver and cord of billroth in spleen (red spleen). Most likely.

Molecules - like Amyloidosis and lysosomal storage disorders etc. Unlikely.

So we double click on cells.

Cells - Large RBCs - unlikely from the hemogram

Large WBCs - Eosinophils themselves are large cells and can explain both.

Large platelets - very unlikely to cause HSM

So Eosinophils infiltrating the spleen and liver can explain enlargement of both organs.

8/17/22, 17:04 - +91 96529 55915: Why lymphadenopathy -

Lymphadenopathy suggests systemic inflammation. Any more detail on this? What was the palpation like? Size of nodes? Any discharge? Tenderness?

Framework for systemic inflammation - I-MADE

Infections - HIV, Leishmaniasis, EBV

Malignancies - Lymphomas and leukaemia

Autoimmune - Sarcoidosis, AOSD

Drugs - DRESS/DIHS 

8/17/22, 17:49 - Shashi Mam Med: Sir yes , they were painless , I could palpate in the cervical , axillary and b/l inguinal lymphnodes measuring 2*2cm 8/17/22, 17:50 - Shashi Mam Med: No discharge sir 

8/17/22, 18:00 - Shashi Mam Med: Yes sir, he took ofloxacin , amoxicillin, rabeprazole , pcm and vitamin

8/17/22, 18:00 - +91 96529 55915: Ohhhhh!! Interesting! So DRESS is a good possibility here.

And this was my learning experience through this integrated teaching that I've encountered during my training in Medschool.

That was me in my final year and then my Internship started wherein I had to be with the cases throughout my 12hrs and 24hrs shifts wherein I’ve shared my experiences in the Successive blogs