Case wise Active learning and discussion-1

Case 1--

 A 42 yrs old with multiple health events


We the MBBS final year students have been given these cases on weekly basis 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 a diagnosis and treatment plan. 



ACTIVE LEARNING AND CONVERSATIONAL DECISION SUPPORT TO TREATING TEAM OF THIS CASE :

  • My active learning discussion:

[5/15, 23:41] Post Residency PG1: 👍
What is the efficacy of the various interventions she has been using and what is the sensitivity and specificity of the various diagnostic interventions she has undergone?
What other history, clinical findings and investigations would you need to solve her problem. 
Also please check her latest update on her symptoms and another additional new diagnosis

[5/16, 14:38] MBBS 2016 UG 3: The latest update says that she is diagnosed with Behcet's disease

[5/16, 14:39] MBBS 2016 UG 3: So maybe Behcet's disease is the reason behind her rashes and mouth ulcers

[5/16, 14:41] MBBS 2016 UG 3: So...pathergy test may help us in confirming the doubt sir

[5/16, 20:10] Post Residency PG1: How was she diagnosed as Behchets disease?

[5/16, 23:34] MBBS 2016 UG 3: Maybe because she satisfied the criteria for diagnosis of Behcet's disese,i.e.,Recurrent mouth sores and skin lesions(major criteria) and genital ulcers

[5/16, 23:37] Post Residency PG1: Is it confirmatory? Ask the original poster if her pathergy test was positive

[5/17, 09:32] MBBS 2016 UG 3: Actually sir....There are no specific tests to confirm the diagnosis of behcet's....pathergy positive just gets us a bit choser to the suspicision...maybe only diagnostic criteria has to be looked into

[5/17, 10:23] Post Residency PG1: Good 

So is their any weightage in the diagnostic criteria such as how many needs to be satisfied to increase the probability of the diagnosis?

[5/17, 21:00] MBBS 2016 UG 3: Yes sir...there is a fixed weightage for the diagnostic criteria to be satisfied.

It is as follows:
-->Presence of recurrent oral ulcerations for at least 3 times in an year
-->Plus any 2 of the following
    -Recurrent genital ulcerations
    -Eye lesions
    -Skin lesions
    -Positive pathergy test

[5/17, 21:06] Post Residency PG1: 👍

[5/17, 21:17] MBBS 2016 UG 3: Thank you sir


  • OTHER DISCUSSIONS:

[5/14, 20:28] Post Residency PG1: I have now been having conversations with some of you in PM and below are my inferences about your current competencies and  possible steps to improve them:

I guess you will need to reframe your approach to the case because many of you are taken up by the title and getting focused on G6PD deficiency in this patient. 

I have asked the original poster to change the title to "A 42 year old woman with multiple health events since birth."

The first step is to prepare a list of all the problems mentioned in order of the patient's priority. 

The next step would be to try and understand each problem and verify as well as validate the diagnosis of the problem.
 
The third step would be to consider what therapeutic options if any are required. 

Let me start your thought process by asking why do you think this patient has G6PD deficiency and when would you consider offering any therapeutic option if any for it?
[5/14, 20:33] Post Residency PG1: Conversational learning in PM (deidentified): 

"[5/14, 7:32 PM] Rakesh Biswas: You have to as a physician ask this question: Does the diagnosis of g6pd matter if we want to help this patient? If so then how exactly does it matter? What are the problems she is facing due to g6pd deficiency? Is she facing those problems?


[5/14, 7:34 PM] +91: Yes sir g6pd diagnosis does matter in this case.. because she has hemolytic episodes and history of anemia since birth


[5/14, 7:36 PM] +9: Due to this there are lot of problems sir related to kidney because of excess hemolysis urobilin is  produced which damages the kidneys


[5/14, 7:36 PM] Rakesh Biswas: Good. Where in the entire case report is that mentioned? When did this problem last affect her?


[5/14, 7:41 PM]: Sir she had many other health events also


[5/14, 7:41 PM] +91: Like pcos, migraine, osteoarthritis

[5/14, 7:43 PM] Rakesh Biswas: Yes as a physician dealing with a patient who has multiple problems you need to prioritize about which one needs significant intervention

[5/14, 7:44 PM] +91: Yes sir.. in this patient G6pd is main priority according to me sir

[5/14, 7:47 PM] Rakesh Biswas: Why?

[5/14, 7:47 PM] +91: In case of recent Hemolytic episode.. we have to first hydrate the patient and then blood transfusion if it is severe

[5/14, 7:47 PM] Rakesh Biswas: What problems does she currently have or when was the last time she had any problem due to her g6pd?

[5/14, 7:48 PM] Rakesh Biswas: When was the last time she had the hemolytic episode


[5/14, 7:51 PM] +91: Sir..She's currently having breathing difficulty,fatigue,oliguria, frequent falls to the left,inadequate sleep,swelling


[5/14, 7:51 PM] Rakesh Biswas: When was that? Please ask the original poster.


[5/14, 7:52 PM] +91: Yes sir it is not mentioned there..


[5/14, 7:52 PM] Rakesh Biswas: 👆message and ask him


[5/14, 7:58 PM] +91: Sir it's may 2019 it seems sir

[5/14, 8:01 PM] Rakesh Biswas: How are these in May 2020?

[5/14, 8:15 PM] +91: Sir Avinash sir also told that.. final diagnosis is  yet to be done

[5/14, 8:20 PM] Rakesh Biswas: That we will make 😅

Ask him what are her current problems in order of priority. If we need to treat or address one problem first which one would it be

[5/14, 8:21 PM]: I'm asking the priority of the current problems to be treated sir
[5/15, 16:36] Post Residency PG1: Check out the latest update of this patient's problems done today to enable you to form a better problem list in order of priority here:

 https://classworkdecjan.blogspot.com/2019/05/42-f-with-severe-regular-edema-with_17.html?m=1 by scrolling down to the bottom.


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