My journey as an internee in medicine department
I Shanegarapu srikar has started my journey as an internee in department of general medicine from 1/12/2023 to 31/1/2024.
General Medicine Department serves as the cornerstone of healthcare, dealing with a diverse range of medical conditions.
Embarking on my journey within the realm of the General Medicine Department has been both enlightening and transformative. This department, often considered the backbone of healthcare, encapsulates the essence of medical practice by addressing a myriad of medical conditions and providing a holistic approach to patient care.
From the outset, I was immersed in the art of history-taking, recognizing its pivotal role in unraveling the intricate tapestry of a patient's health. Learning to navigate through the nuances of each patient's narrative, I discovered that the subtleties often held the key to understanding the onset and progression of their ailments.
My Journey in general medicine department was a roller coaster ride.
Evidence based work flow in general medicine department from 1/12/2023 to 31/1/2024.
I was posted in UNIT 3 from 1/12/2023 to 31/12/2023.
Later I was posted in Psychiatry from 1/1/2024 to 15/1/2024 and then in peripherals from 16/1/2024 to 31/1/2024.
CASE 1:
https://shanegarapusrikarrollno144.blogspot.com/2023/12/39-yr-old-male-with-abdominal.html
39 year old male resident of West Bengal cab driver by occupation came with complaints of Abdominal distension since 2 months,bilateral pedal edema since 2 months,decreased appetite since 2 months,decreased urine output since 1 month.
He was occassional Alcoholic (180ml weekly once) - stopped 1 yr back and Smokes Beedi 1pack/day --stopped 3months back.Vitals during the time of admission was stable but the abdomen was distended.Upon thorough clinical evaluation,shifting dullness was present and fluid thrill was present which showed ascitis and ascitic tap was done and fluid was removed.cardiovascular, respiratory and cns examination was normal.Later,patient complained of haematuria and after doing 24hrs urinary protein and creatinine the protein values were found out to be 3,834 mg/day which served as a bridge for our diagnosis and nephrotic syndrome was suspected in that patient and renal biopsy was done.
I would like to share some videos of procedure of Renal biopsy performed under the guidance of Dr.Krishna Chaitanya sir with Dr.Bharath sir and Dr.Harika mam.It was a good experience to learn the procedure of Renal biopsy using Ultrasound.
CASE 3:
https://shanegarapusrikarrollno144.blogspot.com/2023/12/27-year-male-patient-with-pain-abdomen.html
PAJR link:
https://chat.whatsapp.com/CuH6OmMgTwb0YAfM7QHKN5
CASE 4:
https://shanegarapusrikarrollno144.blogspot.com/2023/12/a-31year-old-male-with-complaints-of.html
Other PAJR Links:
https://chat.whatsapp.com/CfBV81DDZKY4Vd0601qEht
[9/12/2023, 16:24] Dr.Rakesh Biswas Sir: @Dr.Nithin @SNEHA JAJU Kims @Swagath Kims Please get a surgical opinion regarding gallbladder removal
@Srikar please review the literature on gall stone pancreatitis and effect of gall bladder removal on recurrent pancreatitis outcomes
Also @~SR Please share the detailed history and dates of the two events where she had acute pancreatitis
[10/12/2023, 22:34] Dr.Rakesh Biswas Sir: 👆update?
[11/12/2023, 07:20] SNEHA JAJU Kims: Sir I talked with surgery pg regarding it, they told to get the patient to opd on Monday
[11/12/2023, 09:01] Srikar: https://my.clevelandclinic.org/health/diseases/22982-gallstone-pancreatitis
inflammation of pancreas caused by gallstones.
Symptoms:Abdominal pain,Nausea,Vomitings
Treatment:IV fluids,pain relief,bowel rest, nutritional support
Additional treatments may include:
Nausea medication.
Oxygen support.
Antibiotics (if there is an infection detected).
A nasogastric (NG) tube passed through your nose into your stomach to drain fluids.
A urinary catheter to drain your urine and measure your urine output.
Interventions for gallbladder removal:ERCP or gallbladder removal
[11/12/2023, 09:22] Dr.Rakesh Biswas Sir: This is for kg
[11/12/2023, 09:22] Srikar: I am searching for betterones sir
[11/12/2023, 09:23] Srikar: I will post it once I get the better ones
[11/12/2023, 09:24] Dr.Rakesh Biswas Sir: Share some scientific literature that answers our osce patient centred questions regarding the diagnostic and therapeutic uncertainties in managing what we currently think is her recurrent gall stone pancreatitis in a quiescent phase
[11/12/2023, 12:33] Srikar: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2579631/#ref17
gall stones might be a cause of chronic pancreatitis according to these findings, clinical and experimental studies are still needed for confirmation, and further studies are required to determine the mechanisms involved.
[11/12/2023, 14:47] Dr.Rakesh Biswas Sir: Is our patient having chronic pancreatitis?
Why are we looking up chronic pancreatitis?
[11/12/2023, 14:48] Srikar: No sir our patient doesn't has chronic pancreatitis
[11/12/2023, 14:50] Dr.Rakesh Biswas Sir: What does she have?
[11/12/2023, 14:50] Dr.Rakesh Biswas Sir: Share the surgeon's note asap
[11/12/2023, 15:11] Srikar: Gallstone pancreatitis sir
[11/12/2023, 16:06] Srikar: https://www.sages.org/meetings/annual-meeting/abstracts-archive/practice-patterns-for-gallstone-pancreatitis-a-5-year-experience-at-a-community-based-teaching-hospital/
Two hundred seventy two patients met the inclusion criteria. Fifty-six percent of patients had at least one intervention (laparoscopic cholecystectomy, endoscopic retrograde cholangiopancreatography or both) while 44% had no intervention during hospitalization.
Of patients who underwent interventions, 37% had a laparoscopic cholecystectomy (LC) only, 33% percent had ERCP only and 30% had both an ERCP and LC
[11/12/2023, 16:10] Dr.Rakesh Biswas Sir: Share the data in a PICO format.
@~Dr.Dinesh Datta Please guide
[11/12/2023, 16:18] +91 90001 66698: Population-Two hundred seventy-two patients meeting inclusion criteria.
- Intervention-Various interventions including laparoscopic cholecystectomy (LC), endoscopic retrograde cholangiopancreatography (ERCP), or both.
- Comparision-Comparison between patients who had interventions (56%) and those who did not (44%) during hospitalization.
-Outcome-Patients with interventions were associated with factors such as younger age, longer lengths of stay, higher BMI, serum bilirubin levels, liver enzyme levels, and a higher likelihood of antibiotic initiation on admission. Specific interventions were also analyzed, revealing percentages for LC only, ERCP only, and both. Factors influencing the type of intervention included BMI, serum bilirubin, alkaline phosphatase, AST and ALT levels, leukocytosis, and the presence of a CT scan on admission. Additionally, outcomes of positive cholangiograms were discussed, including successful common bile duct explorations (CBDE) and subsequent ERCPs. The success rate of CBDE following a positive intraoperative cholangiogram (IOC) was noted as 21%.
@Srikar convert % to numbers
[11/12/2023, 16:18] +91 90001 66698: And also how desirable Outcomes were measured
[11/12/2023, 16:20] Dr.Rakesh Biswas Sir: And how do the outcomes of the study relate to our current patient requirements?
[12/12/2023, 10:56] Dr.Rakesh Biswas Sir: @~Dr.Dinesh Datta @Srikar What we are interested to know is what are her chances of recurrence in her intermittent acute pancreatitis once we do her cholecystectomy here
[12/12/2023, 10:59] Dr.Rakesh Biswas Sir: We also need to know the event details of each of her attacks of pancreatitis. Maybe I shall have to go and get this history from her myself
[12/12/2023, 11:02] +91 90001 66698: The study population consisted of 524 patients with 126 cholecystectomies. Of these 524 patients, 154 (29·4 (95 per cent c.i. 25·5 to 33·3) per cent) had recurrent disease. The recurrence rate was significantly lower after cholecystectomy than after conservative management (14 of 126 (11·1 per cent) versus 140 of 398 (35·2 per cent); risk ratio 0·44, 95 per cent c.i. 0·27 to 0·71). Even in patients in whom IAP was diagnosed after more extensive diagnostic testing, including endoscopic ultrasonography or magnetic resonance cholangiopancreatography, the recurrence rate appeared to be lower after cholecystectomy (4 of 36 (11 per cent) versus 42 of 108 (38·9 per cent); risk ratio 0·41, 0·16 to 1·07).
Cholecystectomy after an episode of IAP reduces the risk of recurrent pancreatitis. This implies that current diagnostics are insufficient to exclude a biliary cause.
https://bjssjournals.onlinelibrary.wiley.com/doi/full/10.1002/bjs.11429
@Srikar Check if this article is contextual to our patient
Also share the RCTs used in this meta analysis in PICO format.
There should be in references section
[12/12/2023, 11:12] Srikar: https://pubmed.ncbi.nlm.nih.gov/31875953/
Population:- 524patients were taken under the criteria with 126 cholecystectomies
Intervention:recurrence rate was significantly after cholecystectomy:-14 of 126 recurrence rate after conservative management:-140 of 398
Comparison:- comparision between cholecystectomy and conservative management
Outcome:-Cholecystectomy reduces the risk of recurrent pancreatitis.
[12/12/2023, 11:14] Dr.Rakesh Biswas Sir: @SNEHA JAJU Kims @Srikar Share the surgery team Dr Krishnamurti's notes for lap cholecystectomy
Shared the notes for lap cholecystectomy by surgery team
From 01/01/2024 to 15/01/2024 I was posted in Psychiatry where I have seen cases of Schizophrenia, Alcohol dependence syndrome, Depression.
From 16/01/2024 to 31/01/2024 I was posted in Peripherals.
Learning and Procedures performed during my postings:
1.Took ABG samples and learnt how to interpret the report.
2.Inserted Ryle's Tube for feeding.
3.Inserted Foley's catheter for urine output.
4.Learnt about 2D Echo.
5.Monitored vitals during dialysis and learnt about dialysis procedure
6.Done Ascitic Tap
7.Done CPR
8.Assisted Central line and done suturing for it.
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