EVIDENCE BASED DATE WISE WORKFLOW LOGS [OSCE]

 EVIDENCE BASED DATE WISE WORKFLOW LOGS

CASE 1:

PaJR link:

https://chat.whatsapp.com/ITRPEf7cMvU5FKyq5WtQaF

Case report link:

https://chitlaswagathrollno31.blogspot.com/2023/12/39-yr-old-male-with-abdominal.html

PaJR group discussion:

OSCE:

[12/2, 13:11] +91 96188 60147: Sir does he have splenomegaly can we say he his having portal hypertension without spleenomegaly?

[12/2, 14:15] Rakesh Biswas Sir: Yes good question 

Why do some people with high portal pressures get their portal pressures directed toward the splenic vein and inflate it while they may not have any ascites as the portal pressures are not directed to the peritoneal capillaries? Similarly vice versa?

[12/2, 16:05] +91 96188 60147: I think it depends on the cause Sir like if it is prehepatic there will be massive splenomegaly and upper GI bleeding unlike ,in post hepatic where ascites and hepatomegaly predominate .

[12/2, 16:14] Dr.Dinesh Datta: Why splenomegaly but not varices?

[12/2, 16:14] Rakesh Biswas Sir: Right 

So how does portal vein thrombosis incite the portal pressures to be largely diverted to the spleenic vein and not inferior mesenteric vein? 

Why would hepatic cause ascites in alone in some and splenomegaly in some? 

These questions may have some bearing on finding solutions to the problem of how to reduce Portal hypertension. 

What are the current available solutions for reducing portal pressures?

[12/2, 16:22] +91 96188 60147: Varices and other complications develop when Hepatic venous pressure gradient (HVPG) rises above 12 mmHg

And Splenomegaly is the first sign Sir.

[12/2, 16:26] Chitla Swagath: Sir when the portal vein is obstructed, blood finds alternative routes to reach systemic circulation. The splenic vein, which normally drains into the portal vein, becomes a major collateral pathway. Blood from the spleen, stomach, and other nearby organs can then be diverted through the splenic vein, bypassing the blocked portal vein and contributing to increased pressure in the splenic vein.

This diversion to the splenic vein occurs because of the anatomical connections in the portal venous system. The splenic vein communicates with the left gastric vein and short gastric veins, forming anastomoses that allow blood to flow away from the blocked portal vein. In contrast, the inferior mesenteric vein does not have as many direct connections with the splenic vein, so blood is less likely to be diverted in that direction.

[12/2, 16:30] Rakesh Biswas Sir: Are these your hypothesis?

[12/2, 16:50] Chitla Swagath: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8245950/

[12/2, 19:50] Rakesh Biswas Sir: Quote the relevant portion

[12/2, 19:51] Rakesh Biswas Sir: 👆the last sentence doesn't make sense

[12/2, 20:17] Chitla Swagath: Sir i thought maybe the image given in the above article might be reason for more collaterals formed in splenic vessels than inferior mesenteric vessels

[12/2, 20:26] Rakesh Biswas Sir: What portal branch veins are the peritoneal capillaries draining into? 

SMV and IMV? 

So doesn't the portal pressure get deflected more into SMV and IMV for patients that manifest portal hypertension as ascites alone?

[12/2, 20:54] Chitla Swagath: The visceral peritoneum drains through the inferior mesenteric vein, the superior mesenteric vein and the splenic vein into the portal vein.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6328070/

[12/2, 21:19] Rakesh Biswas Sir: That's interesting!! 

So higher splenic vein pressures would not only be expected to balloon the spleen but also cause ascites. But is that observed in clinical practice?

[12/2, 21:21] Chitla Swagath: Not in this patient sir

[12/2, 21:22] Rakesh Biswas Sir: In any patient?

[12/2, 22:07] Chitla Swagath: The spleen stiffness was significantly elevated in the group with ascites as compared with that in the group without ascites 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3747372/

[12/2, 22:19] Rakesh Biswas Sir: What's the implication?

[12/2, 22:39] Chitla Swagath: Sir Spleen stiffness measurement (SSM) is an emerging tool in our arsenal for predicting liver‐related outcomes. It is well established that PH(portal hypertension )leads to spleen tissue hyperplasia, which manifests as splenomegaly and hypersplenism, making spleen stiffness a good predictor of clinically significant PH 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8958239/#:~:text=Spleen%20stiffness%20measurement%20(SSM)%20is,1

[12/2, 22:41] Rakesh Biswas Sir: Nice info 

But it doesn't add to our original question around organ distribution of portal pressures

[12/2, 22:58] Chitla Swagath: Sir this article shows that splenomegaly is associated with ascites in a group study with patients with portal hypertension and control group

[12/3, 10:27] Rakesh Biswas Sir: 👆I can now see why this question may have been misunderstood. 

I was thinking aloud about the possible mechanics of splenic vein pressures leading to splenomegaly and ascites but I meant the incidence of ascites without splenomegaly was substantial enough to contemplate why every portal hypertensive ascites wasn't accompanied by splenomegaly

[12/3, 10:28] Rakesh Biswas Sir: How many patients with portal hypertensive ascites don't have splenomegaly?

[12/3, 20:13] Chitla Swagath: Specific number was not mentioned in this article sir

[12/3, 20:14] Rakesh Biswas Sir: Search other articles

[12/3, 20:14] Chitla Swagath: Ok sir

[12/8, 16:54] Chitla Swagath: Sir patient complains passing this type of urine (4-5 times) since today morning

[12/8, 16:56] Rakesh Biswas Sir: Ask the pathology PGs to check and tell you what it is and then share here asap

[12/8, 16:56] Chitla Swagath: Ok sir

[12/8, 18:57] Chitla Swagath: Sir pathology pg ma'am said to repeat the sample in early morning

[12/8, 20:49] Rakesh Biswas Sir: Severe hematuria! 

What's his PT INR?

[12/8, 22:19] Rakesh Biswas Sir: When was this?

[12/8, 22:22] Chitla Swagath: Today's sample at 9:45 sir

[12/9, 14:44] Chitla Swagath: Usg report sir

[12/9, 20:10] Rakesh Biswas Sir: When done? Why was it needed again today?

[12/9, 20:19] Chitla Swagath: Today morning sir.To rule out BPH or any other cause

[12/9, 20:24] Rakesh Biswas Sir: 39M having hematuria due to BPH!!! 

Who was the brilliant PG who thought this?

[12/12, 11:25] Haripriya Ma'am Gm Pg: @⁨Manisha Ranga Kmni⁩

[12/12, 13:04] Manisha Ranga Kmni: Urine culture

[12/12, 13:19] Rakesh Biswas Sir: Share the macroscopic image of his urine sample asap

[12/12, 13:23] Manisha Ranga Kmni: Already gave him the sample container sir will update as soon as he passes urine sir

[12/12, 14:25] Rakesh Biswas Sir: He's still bleeding 

What's his INR?

[12/12, 14:26] Manisha Ranga Kmni: 1.25 sir

[12/12, 14:31] Rakesh Biswas Sir: What's the bladder ultrasound showing? 

Nothing other than internal echoes of fibrin? 

Cystoscopy?

[12/12, 14:36] Manisha Ranga Kmni: Yes sir only internal echoes

[12/12, 17:03] Manisha Ranga Kmni: They have advised for uroflometry first sir 

And if needed RGU

[12/12, 17:17] Manisha Ranga Kmni: Will get uroflometry done tomorrow sir

[12/12, 17:57] Haripriya Ma'am Gm Pg: Cost ?

[12/12, 18:03] Manisha Ranga Kmni: 500 ma'am

Free for ip free case

[12/12, 19:21] Rakesh Biswas Sir: Get Devendar and Khyati into this as they have some experience on it last time

[12/12, 19:22] Dr.Dinesh Datta: What's the indication?

Frequency?Urgency?Hesitancy?

Or because no clue?

[12/12, 19:26] Manisha Ranga Kmni: Okay sir

[12/12, 19:28] Manisha Ranga Kmni: He is complaining of poor stream of urine since 6 months associated with urgency, hesitancy, intermittency and straining

On and off hematuria

[12/12, 22:03] Rakesh Biswas Sir: Hematuria should have indicated a cystoscopy first

[12/12, 22:50] Manisha Ranga Kmni: Yes sir I did enquire but they have said they would like to rule out stricture urethra first because of the history of poor stream from 6 months sir , which can also explain his hematuria sir

[12/13, 23:14] Manisha Ranga Kmni: Uroflometry

[12/13, 23:14] Manisha Ranga Kmni: Repeat cue

[12/13, 23:17] Manisha Ranga Kmni: Is normal

[12/13, 23:21] Manisha Ranga Kmni: https://en.wikipedia.org/wiki/Rifaximin

[12/13, 23:22] Manisha Ranga Kmni: I could nt find more evidence based article showing incidence of hematuria with rifaximin but urology sir has advised to discontinue it for 3 days and check sir

[12/13, 23:27] Dr.Dinesh Datta: +5 points for Gyrffindor!

[12/14, 08:24] Rakesh Biswas Sir: When is the RGU planned? Again what about the costs? Please check if anything has been done yet on credit

[12/14, 09:00] Manisha Ranga Kmni: No sir as uroflometry is normal, we are not planning for rgu

[12/14, 09:01] Manisha Ranga Kmni: They have asked to continue treating it as cystitis and stop rifaximin and repeat cue after 3 days sir

[12/14, 09:31] Lohith Varma Sir GM Pg: Okay

[12/14, 09:38] Rakesh Biswas Sir: How much did the uroflometry cost? 

What finding in the uroflometry would have made them go for an RGU?

[12/14, 09:58] Manisha Ranga Kmni: It was done for free sir

[12/14, 09:59] Manisha Ranga Kmni: Plateau type of curve sir which would be in favour of stricture sir

[12/14, 10:03] Manisha Ranga Kmni: https://www.researchgate.net/figure/Figures-112A-to-E-Common-uroflowmetry-curves-A-Normal-bell-shaped-curve-B_fig2_305708568

[12/15, 09:12] Rakesh Biswas Sir: Please ask one of the PGs to send our 39M alcoholic cirrhosis with hematuria to Urology opd so that Prof Murthy can evaluate him for a cystoscopy in next 15 minutes as he will leave for OT after that

[12/15, 09:20] Lohith Varma Sir GM Pg: Okay sir

[12/15, 09:24] Manisha Ranga Kmni: Okay sir

[12/15, 19:03] Rakesh Biswas Sir: Milky Urine?

[12/15, 19:04] Rakesh Biswas Sir: @⁨Manisha Ranga Kmni⁩ ?

[12/15, 19:04] Manisha Ranga Kmni: Yes sir this was the evening sample

[12/15, 19:04] Manisha Ranga Kmni: With clot in the bottom

[12/15, 19:06] Manisha Ranga Kmni: Repeat culture which I sent 2 days back is also negative sir

[12/15, 19:07] Rakesh Biswas Sir: But why is it milky? 

Chyluria? Pseudochyluria?

[12/15, 20:21] Manisha Ranga Kmni: Report of the above sample

[12/15, 21:17] Rakesh Biswas Sir: Please start collecting his 24 hour urine for protein and creatinine from tomorrow

[12/15, 22:11] Manisha Ranga Kmni: Okay sir

[12/16, 08:44] Manisha Ranga Kmni: Sir from today I have psychiatry so @⁨Niharika Kmni⁩ will be posting the updates of the case sir

[12/16, 08:49] Rakesh Biswas Sir: @⁨Niharika Kmni⁩ Started medicine internship since when?

[12/16, 08:50] Niharika Kmni: From today onwards sir

[12/16, 08:50] Niharika Kmni: First 15 days i completed psychiatry sir

[12/17, 11:27] Srikar Kmni: Sir, urine sample is cloudy and culture showed no growth; why cnt it be sterile pyuria; if yes, can I go with montoux test

[12/17, 12:01] Rakesh Biswas Sir: Alright 

Also share today's urine

[12/19, 09:04] Rakesh Biswas Sir: Wow!! That's a breakthrough!!

[12/19, 09:06] Rakesh Biswas Sir: Please ask the pathologists for looking at the urine sample for RBC casts and dysmorphic RBCs!! 

What's his serum albumin and last SAAG!!

[12/19, 09:08] Srikar Kmni: I sent this sample for CUE sir

[12/19, 09:09] Srikar Kmni: Casts are nil sir

[12/19, 11:30] Rakesh Biswas Sir: Sit with them and see the sample again. Ask them to check for dysmorphic RBCs

[12/19, 11:32] Niharika Kmni: Ok sir

[12/19, 11:42] Srikar Kmni: Ok sir

[12/19, 11:43] Srikar Kmni: The last SAAG value of the patient sir

[12/19, 12:45] Rakesh Biswas Sir: Share the image of the urine microscopy

[12/19, 14:48] Niharika Kmni: Rbcs- 6-8/hpf

[12/19, 16:29] Rakesh Biswas Sir: 👆image means from the microscope

[12/19, 16:29] Rakesh Biswas Sir: 👆Whom did you sit with and see the sample?

[12/19, 16:34] Niharika Kmni: Sir they are not 

allowing us to take the pic of microscopy unless we get permission from pathology hod or professors

[12/19, 16:35] Niharika Kmni: Pathology pgs in the lab sir

CASE 2:

PaJR link:

https://chat.whatsapp.com/HaiKWKYKbsJ2neyvKqQZjV

Case report link:

https://chitlaswagathrollno31.blogspot.com/2023/12/42-yr-male-with-vomitingloose-motion.html

PaJR group discussion:

OSCE:

[12/5, 16:04] Rakesh Biswas Sir: The posterior part of the arm should also be visible

[12/5, 16:06] Chitla Swagath: Ok sir

[12/6, 13:02] Manideep 2k19: Daily routine of 42 yr male patient :

1) He wake ups at 5:00am in the morning and takes khaini(one pack per 2 days).

2) 5:00- 6:00am = He does brushing, takes bath and chit chats with his neighbours.

3) 6:00-7:30 am- He goes to his 2 acres of land to irrigate.

4) 7:30am = he returns to his house and takes tea.

5) 7:30- 1:30 pm = he goes for labour work in his village.

6) 1:30 - 2:00 pm = launch- rice with one curry at his work place.

7) 1:30- 5:00pm = he continues to do his work.

8) He returns to his house at 5:30 pm and again takes khaini.

9)5:30-8:30 pm= he chit chats with his friends and takes 90 ml of whisky( oc brand ) every day.

10) 8:30 pm = he takes his dinner with rice and curry.

11) at 9:00 pm he goes to bed

[12/6, 13:54] Rakesh Biswas Sir: Share his daily food plates

[12/6, 13:55] Rakesh Biswas Sir: What was he doing on the day he developed the pain abdomen @⁨Chitla Swagath⁩ ?

[12/6, 14:17] Chitla Swagath: He was at his home sir before he developed pain

[12/6, 14:20] Rakesh Biswas Sir: What was he doing? 

How much was his alcohol intake on that day?

[12/6, 14:23] Chitla Swagath: He went to do his field work sir

He took 90ml Alcohol on that day sir

[12/6, 15:38] Manideep 2k19: Sir he takes meals twice a day in the afternoon and night with one bowl of rice and with only one curry( mostly dal). He eats all types of Currys.

He doesn't take breakfast sir.

[12/6, 16:06] Rakesh Biswas Sir: So then our diagnosis of alcoholic gastritis or pancreatitis causing his symptoms was wrong!

If he's consuming 90 ml daily anyways then that couldn't have been the reason for his symptoms?

[12/6, 16:50] Chitla Swagath: Sir i think it might be due to his excess alcohol consumption before he got admitted

[12/6, 16:50] Chitla Swagath: It's elections time sir

[12/6, 16:59] Rakesh Biswas Sir: You said he took 90 ml only on that day!! How much did he actually take?

[12/6, 17:01] Chitla Swagath: He took 90ml on sunday sir(03/12/23)

[12/6, 17:03] Chitla Swagath: He was admitted on 3/12/23

[12/6, 22:02] Rakesh Biswas Sir: How was it different from his routine intake?

[12/6, 22:05] Chitla Swagath: Sir i think he took more than his daily routine during the elections time

CASE 3:

PaJR link:

https://chat.whatsapp.com/CIdLMBj7CGIBYEyAFvsvuj

Case report link:

https://chitlaswagathrollno31.blogspot.com/2023/11/65-yr-old-male-with-sob-fever-and-cough.html

CASE 4:

Case report link:

https://chitlaswagathrollno31.blogspot.com/2023/12/42-male-alcoholic-came-to-de-addiction.html

PaJR link:

https://chat.whatsapp.com/CJDJbZcS4wLBrY0XDOB8un

PaJR group discussion:

OSCE:

[12/16, 21:33] Rakesh Biswas Sir: @⁨Chitla Swagath⁩ Update

[12/17, 18:14] Chitla Swagath: 16/12/23:

S: 3 EPISODES OF LOOSE STOOLS

1 EPISODE OF VOMITING 

O:

ON EXAMINATION:

PATIENT IS C/C/C

Temp: 98.2F

BP:130/70 mmHg

PR:88BPM

RR:18 CPM

Spo2: 98 % on RA

CVS:S1,S2 HEARD ,NO MURMURS 

RS:BAE+, NVBS , NO ADDED SOUNDS

P/A: SOFT, MILD TENDERNESS PRESENT IN EPIGASTRIUM 

CNS: NFND

A:

1. ALCOHOLIC GASTRITIS

2.ALCOHOL DEPENDENCE SYNDROME

P:

1.IV FLUIDS 2 NS, 2RL, 1DNS @100ml/hr

2.INJ ZOFER 8MG IV/TID

3.INJ.PAN 40MG IV/BD

4.TAB SPOROLAC-DS PO/TID

5.TAB OFLOX OZ PO/BD

17/12/23:

S:

NO LOOSE STOOLS

NO VOMITING 

O:

ON EXAMINATION:

PATIENT IS C/C/C

Temp: 98.5F

BP: 130/80 mmHg

PR: 89BPM

RR: 18 CPM

Spo2: 98 % on RA

CVS:S1,S2 HEARD ,NO MURMURS 

RS:BAE+, NVBS , NO ADDED SOUNDS

P/A: SOFT, MILD TENDERNESS PRESENT IN EPIGASTRIUM 

CNS: NFND

A:

1. ALCOHOLIC GASTRITIS

2.ALCOHOL DEPENDENCE SYNDROME

P:

1.IV FLUIDS 2 NS, 2RL, 2DNS @100ml/hr

2.INJ METROGYL 400MG/PO/TID

3.INJ LORAZ 2CC IV SOS (If patient is irritant)

4.INJ ZOFER 8MG IV/TID

5.INJ.PAN 40MG IV/BD

6.TAB SPOROLAC-DS PO/TID

7.TAB OFLOX OZ PO/BD

8.TAB LORAZEPAM PO/TID

9.TAB BACLOFEN XL 20MG PO BD

10.INJ THIAMINE 200MG IV IN 100ML NS/BD

[12/17, 18:31] Rakesh Biswas Sir: In Subj at Day 1 if you recall he was sprawled in the floor drunk! 

When did he become sober?

[12/17, 18:47] Chitla Swagath: On the same day he was little drowsy in the evening but became conscious and able to walk sir

[12/17, 18:54] Rakesh Biswas Sir: Is he currently in the DAC ward?

[12/17, 19:01] Chitla Swagath: No sir in GM male ward

[12/18, 19:09] Chitla Swagath: 18/12/23:

S:

FEVER SPIKE PRESENT 

NO LOOSE STOOLS

NO VOMITING 

O:

ON EXAMINATION:

PATIENT IS C/C/C

Temp: 99.1F

BP: 130/80 mmHg

PR: 86BPM

RR: 17 CPM

Spo2: 98 % on RA

CVS:S1,S2 HEARD ,NO MURMURS 

RS:BAE+, NVBS , NO ADDED SOUNDS

P/A: SOFT, MILD TENDERNESS PRESENT IN EPIGASTRIUM 

CNS: NFND

A:

1. ALCOHOLIC GASTRITIS

2.ALCOHOL DEPENDENCE SYNDROME

P:

1.TAB LORAZEPAM 2MG PO/TID

2.TAB BACLOFEN XL 20MG PO/BD

3.TAB PREGABALIN M 75MG PO/OD

4.TAB BENFOTHIAMINE 100MG PO/BD

Other Blogs that i have updated:

Case report link:

https://chitlaswagathrollno31.blogspot.com/2023/12/65-year-old-male-with-decreased-urine.html

PaJR link:

https://chat.whatsapp.com/LF8S5gSMeP4AydADFbUJnb

PaJR group discussion:

OSCE:

[12/7, 07:23] Rakesh Biswas Sir: @⁨Chitla Swagath⁩ Please organize his entire case report incorporating all that has been shared till now in this PaJR asap

[12/7, 08:02] Chitla Swagath: Ok sir

[12/7, 09:46] Rakesh Biswas Sir: And share the link

[12/7, 09:56] Chitla Swagath: Ok sir

[12/7, 10:50] Chitla Swagath: https://chitlaswagathrollno31.blogspot.com/2023/12/65-year-old-male-with-decreased-urine.html

[12/7, 16:28] Rakesh Biswas Sir: You appear to have just copied the previous case report!! 

We wanted you to copy everything with the handwritten images shared here along with all the texts except any identifiers.

See you haven't added the interventions dose and time in the glucose values you have copied day wise! That would have been very important! 

Also the food plate images at least for one day!!?

[12/7, 16:39] Chitla Swagath: Ok sir i will add them

[12/7, 19:34] Rakesh Biswas Sir: Check out how it's done here 👇

https://userdrivenhealthcare.blogspot.com/2023/12/food-plates-energy-inputs-and-daily.html?m=1

[12/7, 22:04] Chitla Swagath: Updated sir

[12/7, 22:15] Rakesh Biswas Sir: Where is our feedback advise adjusting dose of Insulin after every days blood glucose values? 

You need to update all the texts we made in the group

[12/7, 22:15] +91 94943 50649: Tomorrow they want to come to hospital (narket pally)

[12/7, 22:26] Chitla Swagath: Ok sir 👍

[12/7, 23:00] Chitla Swagath: https://chitlaswagathrollno31.blogspot.com/2023/12/65-year-old-male-with-decreased-urine.html

[12/8, 07:06] Rakesh Biswas Sir: Edit this and similar👇

/3, 22:05] +91 94943 50649: Siddi veerabrahmam

[11/3, 22:28] Rakesh Biswas Sir: 👆@⁨~Deeptha Dhanasekaran⁩

[11/3, 22:30] Rakesh Biswas Sir: అతను ఏ సమయంలో ఏ మందులు తీసుకుంటున్నాడో దయచేసి పేర్కొనండి

Atanu ē samayanlō ē mandulu tīsukuṇṭunnāḍō dayacēsi pērkonaṇḍi

[11/3, 22:50] +91 73825 17519: Ok sir

No one's phone number should be visible in the case report 

Also the patient's name is visible in the very beginning!!?? 

Also please keep the English translations of the telegu I have shared above

[12/8, 08:17] Chitla Swagath: Ok sir

[12/9, 20:46] Rakesh Biswas Sir: Update? 

What happened after they visited Urology yesterday? @⁨~Siddi Nagaraju⁩

[12/9, 20:51] +91 94943 50649: One operation successfully done

[12/9, 20:51] +91 94943 50649: Today morning

[12/9, 20:52] Chitla Swagath: Updated sir

[12/9, 20:52] +91 94943 50649: One more operation is there after two weeks

[12/9, 20:53] Rakesh Biswas Sir: @⁨Chitla Swagath⁩ Find out the details of today's operation from Urology PGs and interns asap

[12/9, 20:58] Chitla Swagath: Ok sir

[12/9, 23:28] Chitla Swagath: circumcision for phimosis was done sir

[12/10, 07:42] Rakesh Biswas Sir: Acquired phimosis due to balanoposthitis which is very common in diabetes?

[12/10, 12:36] Chitla Swagath: Acquired balanoposthitis can be the first clinical sign of DM in uncircumcised males. In a recent study from Britain, 26% of adult patients with an acquired phimosis were found to suffer from type II DM. 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3150172/

Case report link:

https://chitlaswagathrollno31.blogspot.com/2023/12/25-year-old-female-with-chief.html

PaJR link:

https://chat.whatsapp.com/Gnkppp177ySAUAuDXDSjf5

Case report link:

https://chitlaswagathrollno31.blogspot.com/2023/12/40-yr-male-came-with-chief-complaints.html

PaJR link:

https://chat.whatsapp.com/HsTiUTwQt0jAeOfGUCXA6C