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MY JOURNEY IN THE MEDICINE WARDS

1) Self reflective writing on their medical student career 



Im Manisha Ranga , internee at KIMS , Natketpally would like jot down my experiences in the medicine department.

The first day as an intern was a blend of excitement with nervous anticipation. Stepping into the clinical realm as a healthcare professional was a mixture of pride and humility. The responsibility is tangible, and the transition from student to practitioner was palpable. I have joined it with eagerness to apply theoretical knowledge to real-life situations, coupled with the awareness that decisions now directly impact patient well-being. Long shifts, patient interactions, and challenging cases have become part of daily life, fostering resilience and sharpening clinical skills. Life has become a delicate balance between learning, responsibility, and the emotional weight of healthcare decisions.

Learning and unlearning things was indeed a complex task .

This is an online e-log book to discuss our patient's de-identified health data shared after taking his / her / guardian's signed informed consent. Here we discuss our individual patients' problems through a series of inputs from the available global online community of experts to solve those patients' clinical problems with collective current best evidence-based information.


This E blog also reflects my patient-centered online learning portfolio and your valuable input in the comment box is welcome.

Here I would like to reflect on a case that I have seen during my 3 rd prof medicine postings

https://manisharanga132.blogspot.com/2022/10/33-year-old-female-with.html

Pajr 

https://chat.whatsapp.com/IVsV2JINwLSAjzTO8A1RTL

Link to my presentation :

https://youtu.be/Wenz2E9GS-I?si=52tcQKKW0xlQIRRJ


A 33 years old female came to the GM OPD with chief complaints of 

 - Deviation of mouth to right side

 - Weakness of Left Upper Limb on 31/12/2021 at 8:14 am.

History of present illness: 

She was apparently asymptomatic 4 days ago. Then as she was coming out of her washroom she was unable to use her left upper limb followed by which she developed deviation of mouth to the right side. It was associated with drooling of saliva from the right angle of mouth. She also developed parasthesia over face and left upper limb.Her symptoms are improving gradually. She was initially aphasic but now she is able to speak. She also c/o fine tremors in right hand fingers since morning (on 31/12/21).

She was admitted in KIMS, Narketpally 1 month back for Acute GE with polyarthralgia with hypoproliferative marrow.

- No c/o headache.

- No c/o nausea.

- No c/o fever.

- No c/o vomitings.

Link to the blog when she was admitted for the first time is given as follows-

https://medcases1.blogspot.com/2021/12/a-case-of-30-year-old-female.html


Past history: She is a k/c/o SLE on medication since 2 months.

No history of DM, HTN, TB, BA, Epilepsy, CAD.

Family h/o: K/C/O DM and HTN In mother.

Personal h/o: 

Diet -mixed 

Appetite - decreased since 2 months 

Bowel habits - regular 

Bladder habits - regular

Sleep - adequate 

No addictions 

Obstetric history :

Age of marriage - 18

P2L2 

General examination:

 Patient is conscious, coherent,cooperative ,thin built and poorly nourished. 


Deviation of mouth to right side.

Nasolabial fold on left side absent

Mild pallor present.

No icterus, cyanosis, clubbing, lymphadenopathy, Edema.

Vitals: 

Pulse rate - 80 bpm 

Temperature- 98.2 degree Fahrenheit 

RR - 15 cpm 

BP - 100/80 mmHg 

Systemic examination : 

CVS : S1 S2 + , no added murmurs 

RS :BAE + ,NVBS heard 

P/A :soft , non tender 

        No organomegaly 

       No distension 

        Bowel sounds heard

CNS:

GCS- E4V5M6

EOM- Full

Pupils- B/L dilated, reacting to light 

Higher mental functions intact.

Sensory examination was normal 

MOTOR SYSTEM:

Tone-. Rt.                             Lt.

          UL N                               N

          LL. N                                N

Power-

          UL 5/5                            4/5

          LL 5/5                            5/5

Reflexes-

             R.                             L

          B- +                            +

          T -  +                            +

          S- +                             +

          K-+                                +

          A- +                                 +

          P- Flexor                      Flexor

Hand grip 100% 30%

Provisional diagnosis-

CVA WITH LEFT UPPER LIMB MONOPARESIS WITH ACUTE INFARCT IN THE RIGHT PARIETAL LOBE.

SECONDARY TO SLE VASCULITIS.

WITH K/C/O SLE

With K/C/O RUPTURED SEBACEOUS CYST.

Treatment 

1. TAB. ECOSPIRIN 150 mg PO/OD/HS

2. TAB. CLOPIDOGREL 75 mg PO/OD

3. TAB. ATORVASTATIN 40 mg PO/OD/HS

4. INJ. DEXAMETHASONE 8 mg I.V./OD

5. INJ. PANTOP 40 mg IV/OD

6. TAB. HCQ 200 m PO/OD

7. BP/PR/TEMPERATURE MONITORING HOURLY

8. GRBS MONITORING 6th hourly

9. PHYSIOTHERAPY OF LEFT UPPER LIMB


She got discharged and has been on regular medication since then and has come for follow up to our hospital

Im in touch with her via phone calls since past 1 1/2 year along with Dr Durga Krishna sir

She had complaints of blurred vision one year ago.I had taken her to ophthal refferal for examination and I was scared as she is at risk if developing steroid induced cataract and retinopathy changes due to chloroquine.But luckily she had a refractive error and was advised for spectacles.

Her most recent follow up was on 11/1/24 with similar complaints of vision difficulty

Ophthal refferal:

Latest hemogram

CUE
As her albumin was 2+ , we sent for 24 hr urine protein and Creatinine 



She has been a great learning case for me and has given me utmost happiness in how good it feels when the patient has become perfectly fine and living a normal life 

But still her question on how long she has to continue her medication is still a question I have to solve ....

2) Evidence based date wise workflow logs collated by the intern with clickable and verifiable links 



December 1 to 15 

Case 1 

Pajr 

02/12/2023, 10:41 - Manisha Ranga: 1/12
83 year old male pt
S
 intubated in view of low GCS and falling saturations
Ventilator settings
ACMV Vc mode 
Rr 27
FiO2 100
Peep 5
Tv 420 

Pt is sedated
Bp 140/80
Hr 75bpm
No fever spikes 
Cvs S1, S2 heard
Rs crepitations present 
Hb 9.6
Tlc 11,900
Neutrophil predominant 
Plt 3.9
Urea 33
Creat 1.0
Uric acid 2.6


A  
ARDS 
? Community acquired pneumonia 

P
Iv fluids 
Rt feeds
Nebulisations
Day 7 of Moxifloxacin
Day 7 of Doxycycline
02/12/2023, 10:48 - Manisha Ranga: Started on att
02/12/2023, 10:48 - Manisha Ranga: 2/12
83 year old male pt
S
 intubated Day2 
Pt is sedated
Bp 110/70
Hr 75bpm
Sats 100%
Ventilator settings
Tv 430
FiO2 75
Rr 16cpm
Peep 5
No fever spikes 
Cvs S1, S2 heard
Rs b/l crepitations present in infra axillary areas
Hb 9.9
Tlc 16,600 
Neutrophil predominant 
Plt 5.9
Urea 57
Creat 1.6
Uric acid 3.5

A  
ARDS 
? Community acquired pneumonia 
?Aki 

P
Iv fluids 
Rt feeds
Nebulisations
Day 8 of Moxifloxacin
Day 8 of Doxycycline
Att day 2

06/12/2023, 10:05 - A Batch Sathwika: 6/12
83 year old male pt
S
 intubated Day6 
Pt is sedated
Bp 80/50
Hr 88bpm
Sats 100%
Ventilator settings
Tv 400
FiO2 75
Rr 16cpm
Peep 4
No fever spikes 
Cvs S1, S2 heard
Rs b/l crepitations present in infra axillary areas
Hb 8.3
Tlc 14,300 
Neutrophil predominant 
Plt 3.99
Urea 57
Creat 0.9
Uric acid 4.3

A  
ARDS 
? Community acquired pneumonia 
?Aki 

P
Iv fluids 
Rt feeds
Nebulisations
Day 10 of Moxifloxacin
Day 12 of Doxycycline
Att day 7
Inj norad
Inj piptaz
06/12/2023, 10:06 - A Batch Sathwika: <Media omitted>
06/12/2023, 16:44 - Rakesh Biswas Sir: Fever chart since day 1??

Today is day 6 right?
06/12/2023, 16:47 - A Batch Sathwika: No sir it's today's date (6-12-23
06/12/2023, 16:58 - Rakesh Biswas Sir: Merge the two charts asap and reshare
06/12/2023, 22:24 - Rakesh Biswas Sir: @durga writes :

"Bronchoscopy was done-white plague visualised near vocal cords and left pyriform fossa"

https://tdurgasri2019.blogspot.com/2023/12/pre-final.html?m=1


When was this bronchoscopy done? @918106535865 @916304725429 

Did the pulmonology do the bedside bronchoscopy today to detect the source of the sound he was producing today?
06/12/2023, 22:33 - A Batch Sathwika: it was done on 25-11-23
06/12/2023, 22:34 - A Batch Sathwika: Bronchoscopy video sir
07/12/2023, 00:13 - Manisha Ranga: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8170650/
07/12/2023, 00:13 - Manisha Ranga: In conclusion, in patients with ARDS, so far, the available clinical data do not suggest that there is any ideal target PaO2 except for avoiding prolonged exposure (> 24 h) to either hypoxemia, in particular with respect to long-term neuropsychological sequelae [33, 34], or supraphysiological (PaO2 > 100 mmHg).
07/12/2023, 08:18 - Rakesh Biswas Sir: YouTube it after editing identifiers and add to the patient's case report
07/12/2023, 08:20 - Rakesh Biswas Sir: So target PaO2 is less than 100?

What's the corresponding SaO2?
07/12/2023, 08:25 - Rakesh Biswas Sir: Thesis idea :

Let's follow up prospectively our ICU patients on FiO2 with or without ventilation and then try to see the correlation between their SaO2 and PaO2 our hypothesis being "the practice of leaving the patient on an SaO2 of 100 for prolonged periods could be detrimental in terms of inflicting on them high PaO2s affecting their recovery outcomes!

Let's do some more review of literature around this first @918106535865
07/12/2023, 19:16 - Rakesh Biswas Sir: @918106535865 What happened to the morning plan about sharing his serial SaO2's since admission with date, time, fiO2 and PaO2's??
07/12/2023, 19:51 - Dr Akash Deep Gm Pg: <Media omitted>
07/12/2023, 20:22 - Rakesh Biswas Sir: SaO2 is AbG and SpO2 is pulse oximeter? 

Where did we find the SpO2 values? Please share an image of the SpO2 charts if available
07/12/2023, 20:41 - Dr Akash Deep Gm Pg: Yes sir , SaO2 is AbG and SpO2 is pulse oximeter values
07/12/2023, 21:02 - Rakesh Biswas Sir: Where did we find the SpO2 values? Please share an image of the SpO2 charts if available

08/12/2023, 08:15 - Rakesh Biswas Sir: On 4th and 5th the SpO2 never went below 100!!

Do we have any ABG done on those days?
08/12/2023, 09:23 - Dr Akash Deep Gm Pg: Sir these are the ABGs done on 4 and 5 th sir
08/12/2023, 14:56 - Rakesh Biswas Sir: So although the sister's charts show 100% on 4th and 5th, your reports show one ABG that is showing hypoxia!!
08/12/2023, 15:12 - Dr Akash Deep Sir Gm Pg: Yes sir
08/12/2023, 15:17 - Rakesh Biswas Sir: What you have written as 6:00AM is showing 12:00 AM in the ICU desktop computer for this hypoxic sample but at both times it was 100%
08/12/2023, 16:21 - Dr Akash Deep Sir Gm Pg: Okay sir will recheck the abgs and will write the serial abgs
08/12/2023, 16:50 - Rakesh Biswas Sir: @919491489659 @918074920633 Share his EtCO2 from the borrowed EMD device

LEARNINGS FROM THE ABOVE CASE
Target Pa02 in ARDS case
Role of ECMO in severe ARDS 
EtCO2 curves and their causes

Case 2

Blog


Pajr

 
YouTube link WOLTMAN'S SIGN


This was part of final years prefinal osce 

Yesterday's lab results driven diagnosis can also explain her heart failure symptoms
09/12/2023, 11:10 - Kundana Kanumilli: Even ultrasound report came sir
09/12/2023, 11:12 - Rakesh Biswas Sir: Does it reveal anything better than the lab report?
09/12/2023, 11:12 - Rakesh Biswas Sir: 👆Not done?
09/12/2023, 11:16 - Kundana Kanumilli: Updated sir
09/12/2023, 11:17 - Kundana Kanumilli: It shows features of thyroiditis
09/12/2023, 12:55 - Manisha Ranga: https://www.bmj.com/content/364/bmj.l279
09/12/2023, 13:02 - Rakesh Biswas Sir: What are the ultrasound features of thyroiditis? 

What is the sensitivity specificity of those feature in diagnosing thyroiditis?
09/12/2023, 13:05 - Rakesh Biswas Sir: Not updated 
09/12/2023, 13:43 - Manisha Ranga: https://bjbas.springeropen.com/articles/10.1186/s43088-022-00197-0

09/12/2023, 13:46 - Manisha Ranga: This article has shown various usg parameters and their sensitivity in diagnosis of hashimotos 
09/12/2023, 13:48 - Rakesh Biswas Sir: Did our patient have any of these ultrasound findings? 

09/12/2023, 13:50 - Manisha Ranga: <Media omitted>
09/12/2023, 13:50 - Rakesh Biswas Sir: Are these matching your literature review?
09/12/2023, 13:50 - Lahari Jr: USG findings: Altered echotexture and increased vascularity present sir
09/12/2023, 13:51 - Kundana Kanumilli: Yes sir echogenicity and enlarged lymph nodes are present with increased vasculature 
09/12/2023, 13:52 - Rakesh Biswas Sir: Should have been taken from lateral view. 

Do it and take the video again showing the feet from lateral view
09/12/2023, 13:52 - Manisha Ranga: Okay sir
09/12/2023, 15:52 - Rakesh Biswas Sir: Good share it in the 2018 ward group, 2019 and 2021 group and YouTube it and add the case report to the YouTube description box
09/12/2023, 15:58 - Manisha Ranga: Okay sir

My experience with this case :
This case was clear cut example of  laboratory discoveries shaping DIAGNOSIS
Just before we could think of bloom's level 6 moment, we did find similar article with presentation of severe periorbital edema in primary hypothyroidism case


Case 3 

Blog

Pajr

This was also a case in final year students osce , for which I asked the osce and later guided them in completion of the osce for one batch.

Op based follow ups

Followed up a case of 40 year old male with OSTEOMYELITIS of mandible with high blood sugars via phone calls

Followed up a case of acute gastritis with recurrent healthcare visits via phone call

Case 4
Blog 

Pajr 
This was an interesting experience that we cant forget fetus among the f's that cause abdominal distension
The moment I palpated her abdomen, uterus was palpable around 20 weeks and I sent for Upt which turned out to be positive

Case 5
Pajr

I have taken ownership of this case after my friend 
12/12/2023, 13:04 - Manisha Ranga: <Media omitted>
12/12/2023, 13:19 - Rakesh Biswas Sir: Share the macroscopic image of his urine sample asap
12/12/2023, 13:23 - Manisha Ranga: Already gave him the sample container sir will update as soon as he passes urine sir
12/12/2023, 14:19 - Manisha Ranga: 
12/12/2023, 14:25 - Rakesh Biswas Sir: He's still bleeding 

What's his INR?
12/12/2023, 14:26 - Manisha Ranga: Normal sir
12/12/2023, 14:31 - Rakesh Biswas Sir: What's the bladder ultrasound showing? 

Nothing other than internal echoes of fibrin? 

Cystoscopy?
12/12/2023, 14:36 - Manisha Ranga: Yes sir only internal echoes

12/12/2023, 17:03 - Manisha Ranga: UROLOGY REFFERAL
They have advised for uroflometry first sir 
And if needed RGU
12/12/2023, 17:17 - Manisha Ranga: Will get uroflometry done tomorrow sir
12/12/2023, 17:57 - Haripriya Ma'am: Cost ?
12/12/2023, 18:03 - Manisha Ranga: 500 ma'am
Free for ip free case
12/12/2023, 19:21 - Rakesh Biswas Sir: Get Devendar and Khyati into this as they have some experience on it last time
12/12/2023, 19:22 - +91 90001 66698: What's the indication?
Frequency?Urgency?Hesitancy?
Or because no clue?
12/12/2023, 19:26 - Manisha Ranga: Okay sir
12/12/2023, 19:28 - Manisha Ranga: He is complaining of poor stream of urine since 6 months associated with urgency, hesitancy, intermittency and straining
On and off hematuria
12/12/2023, 22:03 - Rakesh Biswas Sir: Hematuria should have indicated a cystoscopy first
12/12/2023, 22:50 - Manisha Ranga: 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
13/12/2023, 23:21 - Manisha Ranga: https://en.wikipedia.org/wiki/Rifaximin
13/12/2023, 23:22 - Manisha Ranga: 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
13/12/2023, 23:27 - +91 90001 66698: +5 points for Gyrffindor!
14/12/2023, 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
14/12/2023, 09:00 - Manisha Ranga: No sir as uroflometry is normal, we are not planning for rgu
14/12/2023, 09:01 - Manisha Ranga: They have asked to continue treating it as cystitis and stop rifaximin and repeat cue after 3 days sir
14/12/2023, 09:31 - Dr. Lohith Varma 🩺: Okay 
14/12/2023, 09:38 - Rakesh Biswas Sir: How much did the uroflometry cost? 

What finding in the uroflometry would have made them go for an RGU?
14/12/2023, 09:58 - Manisha Ranga: It was done for free sir
14/12/2023, 09:59 - Manisha Ranga: Plateau type of curve sir which would be in favour of stricture sir
15/12/2023, 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
15/12/2023, 09:20 - Dr. Lohith Varma 🩺: Okay sir
15/12/2023, 09:24 - Manisha Ranga: Okay sir
15/12/2023, 18:38 - +91 77974 16597: <Media omitted>
15/12/2023, 19:03 - Rakesh Biswas Sir: Milky Urine?
15/12/2023, 19:03 - Rakesh Biswas Sir: @918106535865 ?
15/12/2023, 19:04 - Manisha Ranga: Yes sir this was the evening sample
15/12/2023, 19:04 - Manisha Ranga: With clot in the bottom
15/12/2023, 19:06 - Manisha Ranga: Repeat culture which I sent 2 days back is also negative sir
15/12/2023, 19:07 - Rakesh Biswas Sir: But why is it milky? 

Chyluria? Pseudochyluria?
15/12/2023, 20:21 - Manisha Ranga: Report of the above sample
15/12/2023, 21:17 - Rakesh Biswas Sir: Please start collecting his 24 hour urine for protein and creatinine from tomorrow
15/12/2023, 22:11 - Manisha Ranga: Okay sir


Dec 15 to Dec 31 st PSYCHIATRY POSTINGS

Jan 1 st to 15 
UNIT POSTINGS

Case 1

Blog


Case 2
Case of clinical malaria 
Pajr

Learning point
I understood how clinical suspicion of malaria was the key to start treatment even with negative peripheral smear report

Case 3
Blog

Pajr
YouTube links

Case 4 
Case of pericardial effusion 
Pajr 
 


On 11/1/24  I got a chance to revisit our dissection hall with  students from IIT Hyderabad and I tried to explain the visible important anatomical structures on the cadaver.

Case 5

Pajr

Other cases

Pajr 
This was a family with different medical issues admitted 

Case 1 
40 M with history of gall bladder polyp for surveillance 
Got his usg done and was found to be same as the old reports

Case 2
67 F with anemia and gi distress
She wanted to get endoscopy without pain 
So we arranged it with MONITORED ANASTHESIA CARE 
Endoscopy video

[02/01, 16:25] Rakesh Biswas Sir: @⁨Manisha Ranga⁩ What sedative was used and what was the level of discomfort?
[02/01, 16:38] Manisha Ranga: Propofol was used sir around 70 mg
Patient had no discomfort sir
[02/01, 16:42] Rakesh Biswas Sir: Great job done by Anesthesia team! Now our gastro will start calling them more frequently!
[02/01, 16:42] +91 90001 66698: Why?
Any endo/colonoscopy?
[02/01, 16:44] Rakesh Biswas Sir: Patient's desire for a painless and anxiety free procedure
[02/01, 16:44] +91 90001 66698: What procedure?
[02/01, 16:45] Rakesh Biswas Sir: 👆
[02/01, 17:00] +918159992121: Thank You to all the Doctors for all the support & care.


Jan 16 to jan 31 st PERIPHERAL POSTING
ICU POSTINGS
Learnings
Vitals management
Assisting procedures

On one of my icu day duty 
Realtime bedside osce 


Articles I discussed



Nephro postings
Assisted in central lines
Learnt about the hypertensive urgency management
Learnt about the dialysis parameters

3) Anecdotal self reflections on their internship learning with some evidence of procedures performed

Procedures observed( witnessed the method,noted the steps )
Intubation
Tracheostomy
Usg guided PERICARDIOCENTESIS
Endoscopy under MONITORED ANASTHESIA CARE
Usg guided abscess aspirations

Procedures performed
-Placing ryles tubes 
 foleys catheters
- taken multiple ABG samples
-did ascitic taps 
Assisted central lines
Performed 2 D echoes 


Learning experiences
Witnessed a case of prolonged foleys catheterisation with probably Normal saline inflation which got crystallized and there was difficulty in foleys removal.
It was then removed by usg guided puncture of the bulb .

Difficult RYLES placement
I had difficulty in placing a ryles in an intubated pt with oral guedel's airway as the ryles was getting coiled in the mouth every time 
It was then placed under vision with direct laryngoscopy using Magill's forceps.




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