UNDERSTANDING MEDICINE THROUGH THE EYES OF A NOVICE MEDICAL STUDENT

Lets start off with a salutations

HELLO !

I am Mythili a novice to the never ending World of medicine. Being an undergraduate from the country of India, I present my understanding,or rather the difficulties I faced during the herculean task of accurate diagnosis.

During the course of my curriculum l have learnt that the accuracy of initial diagnosis is critical and forms the fundamental for treatment

So join me on my journey as I try to master the art of diagnosis. 

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.  

Let me tell you about the patient who has helped me open my eyes to the world of diagnostic difficulties

It started off with a lot of excitement as I still could not grasp the fact that I would be going out to the ward to talk to the patient.I saw the patient then , of about 61 year old , similar to my grandfather bought by his second son who was at a loston what to do.

After encouragement of my seniors I went to take history to find out what the problem was.

On talking to the patient it was probably the only reason most of us visit the hospital "PAIN"

However it took me a lot of time to understand where , exactly was it as he seemed not to understand me,

At last his guardians confirmed the below

-Pain in the legs , lower back, and chest pain

-also cough and shortness of breath

However the only thing I could focus on were the rolling pill movement of his right hand and my mind immediately jumped to Parkinson disease which is a classic feature.

On further talking to the guardian I took a very jumbled history which I later on made a timeline of

He also complained of shortness of breath 

Initially he could cycle for lond distance now even walking for short distance results in shortness of breath

There is also history of pedal edema

He is not diabetic or hypertensive however there is increased intake of alcohol and smoking

On further examination vitals were normal: Pulse 81

 Blood pressure 110/80

Respiratory rate 18

My most interesting finding was hearing the apex beat in the 6 th intercostal space

Because of his involuntary movement a detailed CNS examination was done which revealed

-Delay in response

- Resting tremors

-Pill rolling movement in right upper limb 

-Not able to approximate upper limbs

INVESTIGATION have revealed during his stay are showing the following:

Complete blood picture shows total count

Initial Bicytopenia due to reduced RBC and neutrophils has evolved into something else

Initial Hypernatremia and decreased chloride level became Hyponatremia and hyperkalemia and resolved by day of discharge after a week

Chest xray showed bilateral lower lobe consolidation

INITIAL DIAGNOSIS

Bicytopenia (2 to malignancy)

Parkinson disease under evaluation

Community acquired pneumonia

After further investigation

BLOOD SMEAR  SHOWED  Dimorphic anemia with Leucocytosis with atypical Lymphocytes with thrombhocytopenia

After forming a diagnosis a management plan of

Inj AUGMENTIN 1.2g/IV/BD

TAB AZITHROMICIN 500 mg/PO/OD

INJ M6RVIG6M1000 micrograms//IV/OD IN 50 ML NS

TAB PANTOPRAZOLE 40 MG/PO/OD

Vital monitoring

Temperature monitoring

Was done

On discussion of various cause of Leucocytosis a suspicion of malignancy was created

Initially the differential diagnosis were thought to be 

EBV monocytosis 

Wernickie korakoff syndrome

Infectious mononucleosis

Acute lymphoblastic leukemia

However the diagnostic criteria were not met for most of them after studying literature

And the discussion to confirm the diagnosis was started

BONE MARROW BIOPSY showed plasma cell dyscrasia (>30%) 

 After through analysis we found that

Urine bence Jones protein was positive 

High gamma gap

Hypercalcemia

Hyperuricemia

"https://www.sciencedirect.com/science/article/abs/pii/S0889858818303484"

Theese feature show a higher probability of multiple Myeloma

And the case was referred to a cancer center in view of malignancy

For further details please refer the below link

https://munukutlasaimythili.blogspot.com/2022/09/a-case-of-50-year-old-man.html?m=1

PJAR DISCUSSION

 

To begin the conversational learning exercise to finally generate learning outcomes toward patient improvement outcomes let's begin with this question :

What is the relationship between neurodegenerative disorders and development of hematological disorders such as plasma cell leukemia that the patient is currently suspected to have after the bone marrow biopsy done here. 

http://munukutlasaimythili.blogspot.com/2022/09/a-case-of-50-year-old-man.html

Thirteen of 439 multiple myeloma cases had one or more first-degree relatives with degenerative or demyelinating central nervous system disease. In comparison, there were nine "positive" family histories in 1,317 matched hospital controls (relative risk = 4.4, 95% confidence interval = 1.9-10.3). 

Our findings suggest that the degenerative and demyelinating central nervous system diseases and the lymphoreticular malignancies may comprise an etiologically related group of "protean diseases

Our findings may relate also to several laboratory studies in animals. In particular, extensive antigenic cross-reactivity between bone marrow cells and brain tissue has been observed in the BartletP reported that single cell suspensions of adult mouse brain formed hemopoietic colonies in the spleens of ir- radiated host mice. These colonies were identical in morphology and histology to those formed by injection of bone marrow cells but differed in surface antigen composition. Similar colony formation could not be shown with injection of cells from other tissues such as lung, kidney, liver, heart, and thymus. The uniqueness of brain and bone marrow in containing large numbers of pluripotential hemopoietic stem cells suggests that these cells, or their disordered function, might be a com- mon thread linking myeloma and other lymphoreticular malignancies with degenerative and demyelinating CNS diseases

Cited from link

"https://agsjournals.onlinelibrary.wiley.com/doi/pdf/10.1111/j.1532-5415.1989.tb05495.x"

Discussion

Everyone has a few cases during their learning age that form milestones and are always remembered

This case has taught me a lot about history taking because no patient tells the entire story in one day 

I have followed the patient for about a week learning new things about him and yet my seniors had to help me with a few missed points.

That's when I learnt history taking is dynamic,it's evolving and to keep up we have to evolve with it

On further talking to the patient the othe thing that had a very deep impact was the condition of the patient

On the first and second day he could recognise me and was very eager to talk as he was bored in the ward,and I was happy

However the second day evening when I went to see how he was doing ,I was aghast, he couldn't recognise me

But the more saddening thing was he couldn't recognise his own sons .

He couldn't recognise who was first and who was second son.

There was agitation abd altered mental status

When I saw the absolute misery of his family,was eye opening

This was a family suffering,and we couldn't do anything to alleviate their suffering.

I knew I would have to work so much harder to help people

Mysteriously he was fine the third day and recognising his sons again

It was very confusing 

After discharge of the patient we were able to follow the patient far a few days and could know more about his condition which was learnt to be poor prognosis

Regretfully the patient died within 10 days of discharge from the hospital

Which made me wonder

Would he have lived if the condition was discovered 3 years ago? 

This question is my failed learning outcome. 

As said by Vera Lynn

We can't change the past but we can learn from it , 

That is the basis of me writing this article, maybe someday it could help someone learn something

Thank you

REFERENCE

1.https://www.sciencedirect.com/science/article/abs/pii/S0889858818303484

2.https://agsjournals.onlinelibrary.wiley.com/doi/pdf/10.1111/j.1532-5415.1989.tb05495.x

3.http://munukutlasaimythili.blogspot.com/2022/09/a-case-of-50-year-old-man.html

4.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6886439/#:~:text=Diagnostic%20pre%2Drequisite%20criteria%20for,myeloid%20neoplasms%20that%20can%20explain

5.Christina Ramsenthaler, Pauline Kane, Wei Gao, Richard J Siegert, Polly M Edmonds, Stephen A Schey, Irene J Higginson

European journal of haematology 97 (5), 416-429, 2016

https://scholar.google.com/scholar?hl=en&as_sdt=0%2C5&q=symptoms++multiple+myeloma&btnG=#d=gs_qabs&t=1685027570088&u=%23p%3Dzb3rAsqUh90J