My experiences with general cellular pathology in a case based blended learning ecosystem's CBBLE

WARM REGARDS,

I'm Sowmika Marru, a passionate medical student from India. Welcome to my blog, where I share captivating real-life cases that have not only deepened my understanding of history taking and clinical examination but also enhanced my patient interaction skills and overall patient care approach. These cases have been invaluable in shaping my medical journey, and I'm excited to share them with you.

Together, let's delve into the captivating world of patient care, where every interaction holds the potential for learning, growth, and making a positive impact on the lives of those we serve.

Thank you for joining me on this incredible journey!

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.

One of my initial patient interactions was during my 2nd year MBBS (3rd semester) when I was posted in general medicine department. I entered the ward for the fist time and was very anxious because at that time I did not know how to interact and take history from the patient. Then I saw a patient walking across me with abnormal gait and had tremors which grabbed my attention and was curious with my limited knowledge. Then I approached the patient and started interacting to know the cause. I observed he had mask like face, resting tremors and was suppressed on voluntary movement, there was rigidity of the limbs, he was walking fast with short steps and had waddling gait, his wife complained of him having hallucinations and dementia. I was excited with the thought that I may know the diagnosis as one of my relative had similar symptoms and was diagnosed with Parkinson’s disease. This was my first ever case and made me curious about the etiopathogy and differential diagnosis . This interaction stimulated my brain to know more about the case and did my learning that day, so that I could follow up the case and take detail history but unfortunately that day they announced lockdown due to covid 19 and I had to go back to my home.

But I promised “ TO TURN OVER A NEW LEAF ”………….

In my 3rd year ( 5th semester) when I entered the general medicine postings I was allotted a patient in ICU.

CASE 1 :-

A 60 year old male with SOB:-

A 60 year old male came to causality with chief complaints of SOB (grade 4) since 15 days .

SOB associated with orthopnoea. He was already diagnosed with bilateral chronic renal failure and presented with ulcer over leg.

He is an alcoholic with daily intake of 180 ml and also smokes 20 beedis per day.

He had history of seizures when he was 2 years old, H/O COPD and sever anemia.

Presence of pallor and bilateral pedal oedema [ pitting type].

On respiratory system examination- on auscultation- bilateral crepts were heard in IAA , ISA.

On laboratory investigations- serum creatinine is high, blood urea is increased, chloride levels have decreased, haemoglobin is low.

On 2d echo- aortic valve is sclerosed, severe left ventricle dysfunction, all chambers are dilated and diastolic dysfunction.

A frusemide is given to treat oedema, tab orofer and inj erythropoietin 4000 weekly once to treat sever anemia, ecosprin [ low dose aspirin] for preventing stroke and heart attack ( often used as an analgesic for moderate to severe pain). Metoprolol succinate is used to treat high blood pressure, angina pectoris, heart failure, arrhythmia . Ipratropium bromide and levosalbutamol [ Duolin ] used as a nebuliser for COPD.

https://sowmikamarru5.blogspot.com/2021/10/60-years-old-male-presented-with.html

CASE 2 :-

37 year old male with abdominal pain:-

Patient developed sever abdominal pain, squeezing type pain, in the epigastric region which was radiating to back.

He is a auto driver by occupation. He is also an alcoholic. He consumes alcohol daily at night around 180ml from past 15 years, also smokes 4 cigarettes per day and along with it he consumes 10 to 15 packets of gutka [ tobacco] per day from past 10 years .

He was diagnosed with hypertension 3 moths back, he discontinued his medication after taking for one week, even after doctors told him to continue his medication.

He had kidney infection 2 years back.

On laboratory investigations- his haemoglobin is more than normal [ 19.7gm/dl ], random blood sugar level is high [ 203 mg/dl ], fasting blood sugar level is also high [ 176 mg/dl ], increase in total bilirubin, direct bilirubin, AST, ALT, alkaline phosphate, Uric acid.

Serum AMYLASE and LIPASE have increased . [ AMYLASE - 268 IU/L, LIPASE - 94 IU/L ].

On ultrasound of the abdomen , there was bulky head and body of pancreas.

He was diagnosed with acute pancreatitis and De novo diabetes mellitus.

https://sowmikamarru5.blogspot.com/2022/03/a-37-year-old-male-came-with-chief.html

He was kept on fasting [ nil per oral and ryles tube was inserted ]. He was given IV fluid- ringer lactate, he was given ondansetron inj [ ZOFER ] to combat his nausea and vomiting symptoms, PANTOP - it is a proton pump inhibitor which reduces acidity. TRAMADOL to relieve pain . THIAMINE inj is used to treat alcohol induced thiamine deficiency

https://academic.oup.com/alcalc/article/40/2/155/148571

https://med.virginia.edu/ginutrition/wp-content/uploads/sites/199/2021/06/Alcohol-Withdrawal-June-2021.pdf

After few months I met the same patient in the hospital as their family recognised me and told me that he didn’t stop consuming alcohol and came with similar complaints. I observed that the patient has become more irritable, aggressive towards his family. He was told to get admitted in the hospital but he refused and left from there. Doctors informed his wife to convince him for psychiatric counselling but had no response…….

As a 4th year student ( 8th semester) I had started taking my e-logs seriously. I initially felt it was time consuming but eventually I understood that I was able to integrate the topics when I mad a blog, as I was continuously referring to the sources, it made me explore other consequences of the outcome .

“ A WELL EDUCATED MIND WILL ALWAYS HAVE MORE QUESTIONS THAN ANSWERS”

— Helen Keller.

CASE 3 :-

31 year old male with abdominal distension

A lorry driver by occupation came with abdominal distension along with bilateral pedal oedema, yellowish discolouration of sclera.

History of similar complaints in the past and paracentesis was done around one and half year back. 6 months back had hematemesis and melena for which he went to a hospital and was diagnosed with oesophageal varices and had undergone endoscopic varicella ligation.

History of appendectomy.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5934688/

https://www.osmosis.org/answers/esophageal-varices

30 days back he had similar complaints of abdominal distension and discolouration of sclera and was treated in our hospital.

Abdominal pain is in the right hypochondriac, epigastric and left hypochondriac region.

He is an alcoholic from past 20 years- consumes half a bottle of whiskey in a week.

On examination of abdomen- FLUID THRILL is present, hepatomegaly.

He was diagnosed with chronic liver disease.

https://sowmikamarru5.blogspot.com/2022/06/47-year-old-came-with-chief-complaints.html

CASE 4 :-

A 30 year old male came with chief complaints of seizures :-

he had an episode of seizure which lasted for 2 to 3 minutes and was associated with loss of consciousness, up rolling of eye ball, frothing, tonic-clonic movements of upper limb and lower limb, he also felt confused after the episode of seizure and had no recollection of events.

He had similar complaints in the past, 1 year back.

He is a chronic alcoholic from past 7 years, he consumes 360ml of alcohol daily.

He experiences tremors and becomes restless when he did not consume alcohol. Before 2 days of an episode of seizure , he didn’t consume alcohol for 2 days as he wasn’t feeling well.

https://sowmikamarru5.blogspot.com/2022/06/a-30-year-old-male-came-to-casualty.html

He started consuming alcohol from a very young age of 16 year but not regular. He developed this habit seeing his father, as he is also an alcoholic. He started drinking because of curiosity and later he started consuming daily because of family issues.

He was referred to psychiatric department for counselling and for rehabilitation.

He was diagnosed with- seizures secondary to alcohol withdrawal.

https://www.aafp.org/pubs/afp/issues/2004/0315/p1443.html

“ THE CHAINS OF ALCOHOL ARE TOO LIGHT TO BE FELT UNTIL THEY ARE TOO STRONG TO BE BROKEN…….”

CASE 5 :-

A 35 year old female with fever and joint pains:-

3 years back she developed high grade fever which was intermittent type, she usually gets fever in the morning and evening, it is associated with severe joint pains. ( this was in June to August 2020).

Again in the year 2021 ( June to August) she had an another episode of fever and was associated with joint pains.

https://sowmikamarru5.blogspot.com/2022/06/a-38-year-old-female-came-to-opd-with.html

This time she had fever associated with severe joint pains especially in the wrist, ankle and knees.

Presence of morning stiffness.

She had tenderness and swelling over the wrist joint and knuckles.

Her total WBC is increased [ 20000 cells/cumm] .

She tested negative for salmonella typhi, S. paratyphi, plasmodium vivax, plasmodium falciparum.

She was diagnosed with acute febrile illness with reactive arthritis.

https://www.mayoclinic.org/diseases-conditions/reactive-arthritis/symptoms-causes/syc-20354838

CASE 6 :-

A 70 year old female with lower back pain

https://sowmikamarru5.blogspot.com/2022/11/a-70-year-old-female-came-to-opd-with.html

She works in a school as Aaya.

History of femur fracture, operated with proximal femoral nail 4 years back.

3 years back she was diagnosed with carcinoma of cervix II B and underwent radiotherapy.

14 days back she was diagnosed with acid peptic disease and pernicious anemia. She was anemic [ haemoglobin- 4.6mg/dl ] for which she had blood transfusion.

https://www.osmosis.org/answers/pernicious-anemia

Now she was came to opd with lower back pain associated with fever.

No tenderness over the lower back.

On X RAY - there is disc degeneration [ narrowed intervertebral disc space] with osteophyte formation .

She was diagnosed with lumbar spondylosis.

She was treated with DOLO to reduce her fever, NEOMOL inj is an analgesic and antipyretic. Tab ULTRACET is a tramadol hydrochloride and acetaminophen used to tread moderate to sever pain. tab LIVOGEN is used for treatment of anemia. Tab SHELCAL for her daily dose of calcium [ usually elderly people have low calcium and vitamin d3 levels, it is given to prevent further degeneration of bone ]. She is also given multivitamins and minerals tablets [ A to Z tab ]. Tab AMOLONG [ amlodipine ] is a calcium channel blocker used to treat high blood pressure .

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2697338/

CASE 7 :-

A 60 year old female with headache and neck pain:-

She was a daily wage worker and does agriculture, she lives in joint family of 10 members.

She developed fever 10 years back which was associated with joint pains and swelling of the affected joint, she was diagnosed with chikungunya. Presence of morning stiffness and it was relieved on activity.

1 year back she couldn’t raise her arms and had severe back pain. On MRI it showed disc degeneration. Due to limitation of movements she was given injection to shoulder joint and knee joint.

Patient had severe headache in the occipital region and neck pain since 5 years and pain radiating to right shoulder. It is associated with difficulty in moving head from side to side, pain on moving head and there is presence of heaviness in head.

She is a known case of HTN since 20 years and DM since 2 years.

She used to consume alcohol on regular basis but stopped consuming 2 years back when she was diagnosed with diabetes mellitus.

On examination of fingers- she had ulnar deviation deformity on both hands.

Presence of tenderness of the involved joints, and there is restriction of movement.

She was diagnosed with rheumatoid arthritis.

https://sowmikamarru5.blogspot.com/2023/01/a-60-year-old-female-came-to-opd-with.html

For treatment- she was kept on strict diabetic diet . ULTRACET tab [ tramadol hydrochloride and acetaminophen ] used to tread moderate to sever pain. Tab SULFASALAZINE - used in the treatment of rheumatoid arthritis to reduce joint pain, swelling and stiffness. Tab METFORMIN - it reduces blood sugar levels. Tab LOSACAR [ losartan potassium] it is an angiotensin II receptor blocker to treat hypertension, it causes blood vessels to relax and lowers blood pressure.

https://tropmedhealth.biomedcentral.com/articles/10.1186/s41182-022-00412-9

CASE :- 8

35 year old male with blood in stool:-

He is a daily wage labourer, goes to work early in the morning and returns from work by afternoon. He drinks alcohol around 90 to 180 ml [ varies from day to day] and comes home to eat lunch. Again in the evening he goes out to drink alcohol and comes home for dinner and goes to bed.

1 year back he observed blood in stool and not associated with pain

https://my.clevelandclinic.org/health/symptoms/14612-rectal-bleeding

History of SOB [ grade 2] , itching all over the body from past 1 year.

Chronic alcoholic from past 15 years.

On abdominal examination- there is presence of small hyperpigmentation patches on the abdomen.

On laboratory investigations- serum iron is declined, ferritin is low and haemoglobin has also decreased.

He was diagnosed with anemia due to blood loss by haemorrhoids and fissure.

https://sowmikamarru5.blogspot.com/2023/04/35-yr-old-male-with-blood-in-stools.html

CASE 9 :-

36 year old male came with itchy lesions all over the body

He had erythema over the cheeks and nose giving appearance of butterfly rash.

History of photosensitive.

Tenderness in wrist joint , metacarpophalangeal joint, interphalangeal joint.

Presence of oral ulcers on hard palate.

History of CVA +

Alcoholic- consumes alcohol or toddy daily since 20 years. Also smokes Bedi [ 15 per day] since 25 years

On X- RAY of hands there is mild arthritis.

USG report- small shrunken right kidney with grade 3 renal pelvic dilation, grade 2 fatty liver with mild hepatomegaly, right renal cortical cyst.

On laboratory investigations- AST, ALT, alkaline phosphate have increased while albumin decreased. Random blood sugar is low.

This was a peculiar case where patient appears to have vitiligo so he was sent for dermatologist referral but they stated that it was not vitiligo. So we had to continue with our further investigation by doing AANTIBODY TESTING- ANA is +

https://sowmikamarru5.blogspot.com/2023/04/36-year-old-male-came-with-itchy.html

Based on SLICC criteria - photosensitive +, rash +, oral ulcers +, synovitis - tenderness +, no alopecia, no seizures, leukopenia +, thrombocytopenia +, ANA test +, no proteinuria.

[ more than 4 criteria with 1 clinical and at least 1 laboratory criteria] .

Hence he was diagnosed with SLE .

He was treated with SUNCROS AUQAGEL which is a sunscreen, MUCOPAIN GEL is given to relieve pain from oral ulcers. PARACETAMOL was given as an antipyretic. Tab BENFOMET PLUS was given by psychiatric department for alcohol and smoking dependency .

https://www.cdc.gov/lupus/facts/detailed.html

These are just few cases which I could mention, there were many more case that I had taken but due to many reasons they couldn’t come up to blog.

This makes me think that ….. this project made me go through all my cases and also throw light on something’s that were difficult for me to understand before.

“ DIFFICULT AND MEANINGFUL WILL ALWAYS BRING MORE SATISFACTION THAN EASY AND MEANINGLESS”….

- Maxime Lagace.

“ THE LIFE SO SHORT ……, THE CRAFT SO LONG TO LEARN……..”

- HIPPOCRATES.