My experiences with general cellular and neural cellular pathology in a case based blended learning ecosystem's CBBLE

 Warm greetings!

I'm Cherukupalli Lasyapriya, a passionate medical student from India. Welcome to my blog, where I share captivating real-life cases that have not only deepened my understanding of history taking and clinical examination but also enhanced my patient interaction skills and overall patient care approach. These cases have been invaluable in shaping my medical journey, and I'm excited to share them with you.

Together, let's delve into the captivating world of patient care, where every interaction holds the potential for learning, growth, and making a positive impact on the lives of those we serve.

Thank you for joining me on this incredible journey!

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.  

One of my initial patient interactions occurred during my third semester when I encountered a patient in the general medicine department. While passing through the general medicine ward, my attention was captivated by a patient who exhibited distressing skin erosions and blisters. The sight aroused my curiosity, prompting me to approach the patient with the aim of comprehending the underlying etiopathology.

The patient, an elderly gentleman in his seventies, bore a nearly complete coverage of blisters that ruptured, leading to skin erosions. Suffering from immense pain, the patient displayed disinterest in engaging with the students. Consequently, I sought out one of the residents assigned to the ward to gain insight into his condition. The resident graciously and patiently elucidated that the patient was afflicted with Pemphigus vulgaris.

As a third-semester student, my knowledge of Pemphigus vulgaris was exceptionally limited. This encounter marked my inaugural exposure to an individual with an autoimmune disease, as well as my initial encounter with a patient exhibiting such severe dermatological manifestations.

Little did I know, this encounter was merely the tip of the iceberg, offering a glimpse into the myriad experiences awaiting me in the forthcoming semesters within the general medicine department.

 24 year old Male with Hematemesis

One of the cases that I encountered during my initial days was that of a 24-year-old male patient, a carpenter by profession and hailing from Chitavaram, who presented to the hospital with a chief complaint of experiencing two instances of hematemesis (bloody vomiting) and chest pain for about 24 hours.

https://lasyapriyacherukupalli26.blogspot.com/2021/10/a-24-year-old-male-with-hematemesis.html

Two days prior, the patient was reportedly free from any symptoms. However, on the day of presentation, he engaged in uninterrupted alcohol consumption from morning till night, without having any food. During the night, he began to vomit, and the vomitus was characterized as non-bilious and non-projectile, with the presence of blood. Subsequently, the patient lost consciousness. He was admitted to the hospital during the late hours, specifically between 1 am and 2 am.

The patient also reported chest pain, which began after the vomiting episodes. The pain was described as a pricking sensation, continuous in nature, and localized in the central region of the chest.

When I enquired about his past history, I found out that the patient had no previous medical records of similar complaints.

Approximately six years ago, the patient commenced regular alcohol consumption in the company of his friends. Initially, he consumed 180ml of whiskey per day, which progressively escalated to 540ml due to diminishing desired effects. Concurrently, he also initiated the habit of chewing tobacco, which he has sustained for the past four years, with a daily consumption of approximately two packs. Furthermore, the patient abstains from alcohol for two months annually as part of religious observance. During this period, he encounters symptoms such as tremors and disturbances in sleep.

There is no medical history of diabetes, hypertension, liver disease, tuberculosis, asthma, epilepsy, coronary artery disease (CAD), or cerebrovascular accident (CVA).

There weren’t any significant examination findings.

Based on the provided information, a diagnosis of Mallory-Weiss Syndrome was made which is characterized by bleeding from a tear in the mucous membrane of the esophagus or stomach, typically caused by severe or prolonged vomiting.

The patient's history of alcohol consumption, episodes of vomiting, and subsequent bloody vomitus align with this condition.

The individual was released from the healthcare facility the following day after receiving comprehensive guidance regarding the deleterious consequences of their ongoing conduct. They were strongly advised to either restrict or completely abstain from alcohol consumption. This particular case offered valuable illumination into the progression of addiction, starting with a seemingly innocuous experimentation with substances and gradually dismantling an individual's existence.

 37 Year old Male with Swelling of Lips and Face

As a fourth-year student, I encountered a comparatively recent and noteworthy case involving a 37-year-old male afflicted with Angioedema. Engaging in telephonic case taking, I directly communicated with the patient to acquire a comprehensive account of his symptoms, aiming to gain a deeper comprehension of his medical condition. Although I had access to the patient's case report, I considered it imperative to personally interact with him to gather a more nuanced understanding of his situation.

https://lasyapriyacherukupalli26.blogspot.com/2023/03/1801006023-short-case.html

Sixteen years ago, the patient appeared to be asymptomatic until an incident in 2007 when exposure to cement dust triggered sudden respiratory distress, speech impairment, and extensive swelling of the face, lips, hands, and legs. An emergency tracheostomy was performed, followed by conservative treatment that successfully alleviated the symptoms. Further investigation revealed the patient's allergies to smoke from burnt plastic, offensive odors, straw dust, and cotton, as well as specific food allergens such as Brinjal, mutton, fish, and papaya. Notably, anxiety seemed to exacerbate the symptoms, and facial swelling intensified following any history of trauma.

 

Over the course of the past 16 years, the patient experienced intermittent symptom episodes. In 2011, the patient was referred to an external hospital for immunotherapy, receiving undisclosed medications and precautionary measures against allergens. However, in 2016, the patient relapsed with symptoms resembling those present during the 2007 incident, necessitating the administration of medication to relieve occasional facial, hand, and leg swelling.

In 2021, the patient sought medical attention once again due to facial swelling and breathing difficulties. Treatment included fresh frozen plasma (FFP) transfusion, adrenaline administration, nebulization, and hydrocortisone, which effectively alleviated the symptoms. Throughout the past 16 years, the patient has experienced approximately 6-7 hospital admissions.

Regarding the patient's past medical history, there is no known history of hypertension (HTN), diabetes mellitus (DM), coronary artery disease (CAD), thyroid disorders, epilepsy, or tuberculosis.

In terms of personal history, the patient follows a mixed diet with a normal appetite. They report adequate sleep and regular bowel and bladder movements. There are no addictive behaviors. Additionally, the patient exhibits allergies to straw dust, burnt leaves, garbage, and smoke from burnt plastic, as well as specific food allergies to Brinjal, mutton, fish, and papaya.

A laboratory test conducted in December 2020 revealed that the patient had a C4 complement serum level below 8 mg/dl and a C1 esterase inhibitor protein level of 65 mg/dl.

The patient was diagnosed with Hereditary Angioedema.

The patient manages his illness by avoiding allergens which trigger his symptoms and uses Tab. Levocetirizine during mild exacerbations of his symptoms.

This case offered valuable insights into the effective management of chronic and potentially incapacitating disorders through conservative measures, emphasizing the significance of lifestyle modifications and minimal reliance on medication.

 50 Year Old Male with Acute Right Sided Weakness

During my clinical experience as a final year student, I encountered a remarkable case involving a 50 year old male patient who presented with acute right-sided hemiparesis. This particular case exemplified a classic presentation of a cerebrovascular accident (CVA), allowing me to further solidify my understanding of spinal cord tracts and their role in localizing the affected area of the CVA. It served as a valuable learning opportunity, enabling me to apply my knowledge to real-world clinical scenarios and enhancing my comprehension of neurological conditions.

https://lasyapriyacherukupalli26.blogspot.com/2023/03/1801006023-long-case.html

 

One month prior, the patient experienced sudden dizziness and weakness in the left upper and lower limbs, which led to a fall. Promptly, the patient was admitted to the hospital where they received treatment and were diagnosed with hypertension. Fortunately, his symptoms resolved within a span of approximately three days. Initially, the patient diligently adhered to his prescribed hypertension medication for a period of 20 days but discontinued it thereafter

Three days ago, the patient suddenly developed weakness in the right upper and lower limbs. He became aware of this weakness upon awakening in the morning and experienced a feeling of unsteadiness when attempting to stand. Moreover, the weakness on the right side was accompanied by slurred speech and a deviation of the mouth to the left side. Subsequently, the patient was transported to a nearby hospital, where they underwent a CT scan. Following the CT scan, they were then referred to our hospital the next day.

It is worth noting that the patient has no history of swallowing difficulties, behavioral abnormalities, fainting episodes, sensory disturbances, fever, neck stiffness, changes in consciousness, headache, vomiting, seizures, abnormal movements, or previous falls.

The patient also has a history of fracture sustained close to his right elbow 30 years ago. He currently cannot extend his elbow completely.

Coming to personal history, the diet is mixed, and appetite is normal. The patient maintains a consistent sleep schedule and goes to bed by 9:00 pm.

Additionally, it is important to note that the patient has been using chewing tobacco for approximately 10 years, with one packet lasting for two days. He has also been consuming alcohol regularly for the past 30 years. There was a period of abstinence for around three years, but he resumed alcohol consumption six months ago following the death of his daughter's husband.

The patient reports regular bowel and bladder movements.

The following are his examination findings.

1. Neurological Examination:

- Higher mental functions are intact: The patient's cognitive functions, such as memory, attention, and language, are normal.

- No meningeal signs: There are no signs of inflammation or irritation of the meninges (the membranes surrounding the brain and spinal cord).

- Glasgow scale - 15/15: The patient scored the maximum points on the Glasgow Coma Scale, indicating full consciousness and alertness.

- Gait - walks only with support: The patient requires assistance while walking, suggesting impaired balance or weakness in the lower limbs.

- Cranial nerves:

  - VII (Facial nerve): Deviation of the mouth to the left side, but the upper half of the right side and the left side function normally.

 - All the other cranial nerves were normal bilaterally on examination

- Pupils: Both pupils are normal in size and reactive to light.

2. Motor Pathway:

- Power:

  - Right upper limb (UL): Strength is graded as 3/5.

  - Left upper limb (UL): Strength is graded as 5/5.

  - Right lower limb (LL): Strength is graded as 3/5.

  - Left lower limb (LL): Strength is graded as 5/5.

- Tone:

  - Right upper limb (UL): Increased tone.

  - Left upper limb (UL): Normal tone.

  - Right lower limb (LL): Increased tone.

  - Left lower limb (LL): Normal tone.

- Reflexes:

  - Biceps, Triceps, Supinator, Knee, and Ankle reflexes are exaggerated on the right side compared to the left side.

  - Plantar reflex (Babinski sign): Muted response, indicating a normal flexion response.

3. Sensory System:

- Pain, temperature, crude touch, and pressure sensations are normal.

- Fine touch, vibration, and proprioception are normal.

- No abnormal sensory symptoms.

4. Cerebellum:

- Finger-nose test normal, indicating accurate coordination of movements.

- No dysdiadochokinesia (inability to perform rapid alternating movements).

- Rhomberg test could not be done (an examination to assess balance and coordination).

5. Autonomic Nervous System: Normal function.

The examination of Cardiovascular system, respiratory system and abdomen yielded no significant findings.

Upon reviewing the patient's medical history and conducting a thorough examination, a diagnosis of acute cerebrovascular accident (CVA) affecting the posterior limb of the left internal capsule has been established.

Subsequently, the diagnosis was further substantiated through the utilization of brain MRI.

Throughout the patient's hospitalization, there was a gradual amelioration observed in the motor function of the affected side. Consequently, it was deemed prudent to recommend physiotherapeutic interventions aimed at maximizing his recuperation. Moreover, the patient received counseling regarding the imperative nature of strict adherence to his prescribed medication regimen, which is vital for mitigating the potential for future stroke occurrences.