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

This is Deepika ,a medical student from India. As a student in the general medicine department, I embarked on a transformative journey, witnessing challenges and complexities of patient care. In this platform, I will share the glimpse into my journey in the department and recount my experiences and invaluable lessons I gained during my time in the department.

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

In the case - based blended learning ecosystem (CBBLE), I had great experiences studying general cellular and neural cellular pathology. I learned about cellular changes in different diseases and how they affect the body. The case -based approach helped me apply my knowledge to real-life situations, improving my diagnostic skills and critical thinking. Collaborating with classmates and receiving feedback from instructors made the learning process engaging and interactive. The use of technology, like virtual microscopy and online discussions, made learning accessible and flexible. Overall, my time in the CBBLE gave me valuable knowledge and skills that I can use in clinical practice and research.

My Journey in the General Medicine Department: A Student's Perspective (2018-2023)

Introduction:

Embarking on my journey as a medical student in the General Medicine Department in 2018, I was filled with a mix of excitement, curiosity, and a deep sense of purpose. Over the course of five transformative years, I had the privilege of immersing myself in the world of medicine, witnessing the triumphs, challenges, and profound impact of healthcare on patients' lives. In this blog post, I will share a detailed account of my journey in the General Medicine Department from 2018 to 2023, highlighting the milestones, experiences, lessons, and personal growth I experienced along the way.

1. The Early Years: Building the Foundation (2018-2020)

The first years of my medical education were focused on laying a strong foundation of medical knowledge. I attended lectures, participated in practical sessions, and dedicated countless hours to studying anatomy, physiology, pharmacology, and other fundamental subjects. The rigorous curriculum instilled discipline, critical thinking skills, and the ability to assimilate vast amounts of information.

2. Clinical Exposure: Stepping into the Hospital (2021-2022)

 In the clinical years, I transitioned from the classroom to the hospital environment. I vividly remember the excitement and nervousness as I donned my white coat and stepped into the wards. Under the guidance of senior physicians and residents, I began interacting with patients, taking medical histories, and performing physical examinations. These hands-on experiences helped me develop vital skills in patient communication, clinical reasoning, and forming differential diagnoses.

3.Rotations in Various Specialties.

During my rotations in the General Medicine Department, I had the opportunity to delve into various subspecialties, including cardiology, pulmonology, gastroenterology, nephrology, and endocrinology, among others. Each rotation exposed me to different patient populations, diagnostic challenges, and treatment modalities. I actively participated in patient care, attended ward rounds, and observed and assisted in various procedures. These rotations broadened my understanding of the diverse spectrum of medical conditions and allowed me to appreciate the complexities of managing complex cases.

4. Interprofessional Collaboration: Learning from Peers 

Collaboration with fellow medical students, nurses, pharmacists, and other healthcare professionals was a cornerstone of my journey in the General Medicine Department. Through interdisciplinary discussions and teamwork, I learned the importance of effective communication, mutual respect, and shared decision-making. Working together with professionals from different backgrounds enriched my learning experience, broadened my perspectives, and highlighted the value of a multidisciplinary approach to patient care.

5.Patient Stories: A Lesson in Compassion 

Interacting with patients and hearing their stories was a constant reminder of the human side of medicine. I witnessed moments of vulnerability, strength, hope, and resilience in the faces of those fighting illness. Each patient's journey provided me with valuable insights into the profound impact healthcare professionals can have on individuals and their families. These experiences reinforced the importance of empathy, active listening, and treating patients with compassion and dignity.

Coming to my case

It was a14 year old female who was quite alright when I saw her my first impression on the girl  was she is perfectly alright so I was intrigued on why she came to the hospital as I walked closer towards her I could see her hyperventilate the I approached her and asked her problems to which she said she had the complaints of shortness of breath ,fever, abdominal pain and vomitings. She said she had fever and abdominal pain from 1 day along with shortness of breath from 2 days. There was no notable visible abnormalities in her like pedal edema, pallor etc. The further treatment was done along with investigations. You can take a detailed report of the case in my blog:

http://deepikamanupatirollno194.blogspot.com/2023/04/14-year-old-female-with-shortness-of.html

The diagnosis came to be as diabetic ketoacidosis to which the lady was treated appropriately and sent home.

Coming to my case:

A 50 year old man who's a resident of nakrekal ,labourer by occupation came to the opd to get admitted under de - addiction and is found to be having high blood sugar levels and was sent to the medicine department 

Diving into the history patient was apparently asymptomatic 4 years back ,then he developed 

• Burning type of pain in the right and left hypochondrium,3 to 4 episodes for which he went to a local hospital and got medications(He's a chronic alcoholic since 30 years), and the symptoms subsided,his last episode was the day after he got admitted here and was given pantop iv and the symptoms subsided. 

• H/o weight loss approximately 20 kgs since 15 months

• 1 year back he was found to have high Sugars at a government camp at his place used OHA's for 4 months 

• Then he developed complaints of Generalized weakness, polydypsia, poly urea for which he visited a private hospital at Nakrekal found to high sugars (Uncontrolled DM 2 ) He was on insulin(10 U morning,5U in the night) since then (took Insulin Irregularly) .

• Complaints of Diminution of vision since 8 months and double vision in the mornings since 7 months

• H/o light trauma 3 month back then he developed bubble like lesions along the right 3-4ICS , associated with pain and itching for which he went to a local hospital and got some medications and pain and itching decreased in intensity ,later Complaints of shooting type of pain along the dermatome (on right side of 3-4 ICS,intermittent in nature,occuring one or twice for about 5 to 10 minutes once in 3days since 29/7/22 ,associated with itching and tingling sensation

• H/o Trauma (with mild skin abrations over the ankles and bony prominences ) 15 days back,then he developed itching over the wounds

Came to the opd and got admitted for de-addiction and was sent to GM for uncontrolled DM 2(550mg/dl)

• Complains of body pains since 3 days for which he was given tramadol 

• Vomitings on 1/8/22 morning 

2 episodes ,projectile type with food particles as content( early in the morning& after consuming milk) for which he's given medication and the symptoms subsided

• Burning type of pain in the right and left hypochondrium and epigastric regions since 2/8/22 on and off for 1to 2 hours in a day 

• Fever since 3/8/22 which is low grade, intermittent in nature, not associated with chills and rigor and got relived on medications.

Diagnosis: Chronic Alcoholism with Uncontrolled Diabetes Mellitus 2 with Post Herpetic Neuralgia.

You can take a detailed report of the case in my blog:

http://deepikamanupatirollno194.blogspot.com/2023/04/medical-case-disscussion-july-282022.html

Coming to my case:

A 48 year old male came with chief complaints of abdominal distension from past 20days,was insidious in onset and gradually progressed to present size and not associated with abdominal pain.

10 days back , he went to a local hospital where was given medication, but didn’t give him relief.

H/o SOB (progress Ed from grade 1 to 2 ) It increased on exertion and relieved on taking rest.

H/o increased frequency of stools on 15th and 16th April, hard in consistency, green in colour, 5 episodes per day, blood stained and had 5 to 6 drops of blood at the end of defecation. It is not associated with pain and relieved on medication.

H/o bilateral pedal edema since 15 days which is pitting type and extending till the knee joint.

He has decreased urine output since 10 days.

Not associated with burning micturition,orthopnea , PND,fever, nausea, vomitings,chest pain, giddiness, cough

History of jaundice in the past- 2 years back and 6 months back and was managed conservatively with medication.

K/c/o Hypertension since 10 years, initially was on T.TELMA 80 mg which was later reduced to T.TELMA 40 mg and now the patient is on T.amlong 5mg and atenolol 50mg.

Diagnosis: De- Compensated Chronic liver disease , k/c/o hypertension

This encounter made me feel compassion for the patient's suffering and a deep sense of responsibility, reminding me of the immense impact our work can have on the lives of those in need. It solidified my commitment to provide the best care possible and find answers for patients like him.

You can take a detailed report of the case in my blog:

http://deepikamanupatirollno194.blogspot.com/2023/04/a-48-year-old-male-with-abdominal.html

PJAR Discussion :

Project : Clinical complexity in patients with low backache

Learning points : 

✓✓✓ JOA scoring https://www.researchgate.net/figure/The-Japanese-Orthopaedic-Associations-scoring-system-JOA-Score_tbl1_268790894

✓ ✓✓what would the successful treatment for back ache? , Is the success duration dependent

https://pubmed.ncbi.nlm.nih.gov/30658613/

We analysed 3859 patients with Lumbar Spinal Stenosis [(LSS); mean age 66; female gender 50%] and 617 patients with Lumbar Degenerative Spondylolisthesis [(LDS); mean age 67; 72% female gender]. The accuracy of identifying 'completely recovered' and 'much better' patients was generally high, but lower for EQ-5D than for the other PROMs. For all PROMs the accuracy was lower for the change score than for the follow-up score and the percentage change score, especially among patients with low and high PROM scores at baseline. The optimal threshold for a clinically important outcome was ≤24 for ODI, ≥0.69 for EQ-5D, ≤3 for NRS leg pain, and ≤ 4 for NRS back pain, and, for the percentage change score, ≥30% for ODI, ≥40% for NRS leg pain, and ≥ 33% for NRS back pain. The estimated cut-offs were similar for LSS and for LDS.

Conclusion: For estimating a 'success' rate assessed by a PROM, we recommend using the follow-up score or the percentage change score. These scores reflected a clinically important outcome better than the change score.

https://pubmed.ncbi.nlm.nih.gov/12973134/

Sixty-four patients aged 25-60 years with low back pain lasting longer than 1 year and evidence of disc degeneration at L4-L5 and/or L5-S1 at radiographic examination were randomized to either lumbar fusion with posterior transpedicular screws and postoperative physiotherapy, or cognitive intervention and exercises. The cognitive intervention consisted of a lecture to give the patient an understanding that ordinary physical activity would not harm the disc and a recommendation to use the back and bend it. This was reinforced by three daily physical exercise sessions for 3 weeks. The main outcome measure was the Oswestry Disability Index.

Results: At the 1-year follow-up visit, 97% of the patients, including 6 patients who had either not attended treatment or changed groups, were examined. The Oswestry Disability Index was significantly reduced from 41 to 26 after surgery, compared with 42 to 30 after cognitive intervention and exercises. The mean difference between groups was 2.3 (-6.7 to 11.4) (P = 0.33). Improvements inback pain, use of analgesics, emotional distress, life satisfaction, and return to work were not different. Fear-avoidance beliefs and fingertip-floor distance were reduced more after nonoperative treatment, and lower limb pain was reduced more after surgery. The success rate according to an independent observer was 70% after surgery and 76% after cognitive intervention and exercises. The early complication rate in the surgical group was 18%.

https://pubmed.ncbi.nlm.nih.gov/30658613/

A study compared lumbar fusion surgery with cognitive intervention and exercises in 64 patients with low back pain and evidence of disc degeneration. The main outcome measure was the Oswestry Disability Index. Results showed that the Oswestry Disability Index was significantly reduced from 41 to 26 after surgery, compared with 42 to 30 after cognitive intervention and exercises. The success rate according to an independent observer was 70% after surgery and 76% after cognitive intervention and exercises. The early complication rate in the surgical group was 18%.

Surgery is not always the best option: Clinical trials have shown that low back pain surgery may not always be the best treatment option for patients with chronic low back pain. In some cases, non-operative treatments such as cognitive intervention and exercises may provide similar outcomes to surgery.

The JOA score can be used to assess the need for surgery in our patients with low back pain. A score of more than 7 can be conservatively treated, while a lower score may indicate the need for surgery.

✓✓✓ Failed back surgery syndrome

Failed back surgery syndrome (FBSS) is a term used to describe persistent or recurrent low back pain following spinal surgery. It is a complex condition that can have a significant impact on the quality of life of patients. The reasons why surgery may fail are multifactorial and can include incorrect diagnosis, inadequate surgical technique, complications during surgery, and underlying medical conditions. 

Some common symptoms of FBSS include chronic pain, numbness, tingling, and weakness in the back and legs. Treatment options for FBSS may include physical therapy, medications, nerve blocks, spinal cord stimulation, or revision surgery. It is important to consult with a healthcare provider to determine the best treatment plan for individual cases of FBSS.

✓✓✓Discectomy vs Sham surgery 

https://pubmed.ncbi.nlm.nih.gov/12973134/

This study compared two treatments for long-term low back pain. One group received surgery, and the other group received exercises and education. After one year, both groups had improved, but the surgery group improved slightly more. However, the differences were not significant, meaning they could have happened by chance. The surgery group had more complications than the exercise group. Overall, both treatments were helpful for most patients, but surgery had more risks.

✓✓✓Why was our patient on sulfasalazine 

In the case of lower back ache, Sulfasalazine may have been prescribed if the patient is suspected to have an inflammatory condition, such as ankylosing spondylitis or psoriatic arthritis

✓✓✓https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4501532/#:~:text=Based%20on%20antero%2Dposterior%20diameter,mm2%20are%20severely%20stenotic.

Based on antero - posterior diameter of spinal canal or on the cross sectional area of the dural sac, lumbar canal stenosis can be diagnosed. Cross sectional area of dural sac >100 mm² at the narrowest point is normal and 76–100 mm² is moderately stenotic and <76 mm² are severely stenotic

✓✓✓https://pubmed.ncbi.nlm.nih.gov/12973134/

This study compared two treatments for long-term low back pain. One group received surgery, and the other group received exercises and education. After one year, both groups had improved, but the surgery group improved slightly more. However, the differences were not significant, meaning they could have happened by chance. The surgery group had more complications than the exercise group. Overall, both treatments were helpful for most patients, but surgery had more risks.

Hence we went forth with cognitive interventions consisting lumbar back support painkillers (pregabalin ,duloxetin ),pyscho education as our patient score was 9

7. Research and Scholarly Activities 

Engaging in research and scholarly activities played a significant role in my journey. I had the opportunity to participate in research projects, present posters at conferences, and contribute to scientific publications. These experiences fostered critical thinking, enhanced my understanding of evidence-based medicine, and cultivated a lifelong appreciation for the importance of research in advancing medical knowledge and patient care.

8. Personal Growth and Resilience: Overcoming Challenges 

The general medicine department ignited my passion for lifelong learning and research. I immersed myself in exploring the latest medical advancements, reading research papers, and engaging in scholarly discussions. Participating in research projects allowed me to contribute to the expanding body of medical knowledge and fostered critical thinking skills that I can apply to future patient care.

Conclusion:

My journey as a medical student in the general medicine department has been a transformative, challenging, and immensely rewarding experience.