GENERAL MEDICINE-2

GENERAL MEDICINE MONTHLY ASSIGNMENT

135 UMR.AKANKSHA

"This is 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 patient’s problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs"

QUESTION-1

Please go through one student's entire answer paper from this link, the one who is closest to your own roll number :

http://medicinedepartment.blogspot.com/2021/07/2019-batch-medicine-department-online.html?m=1

and share your peer review of each answer with your qualitative insights into what was good or bad about the answer. 

ANSWER-1

https://vagisharani.blogspot.com/

I have gone through one of my friends blog which is close to my roll number.

*My review on the blog is;

The case is well presented and explained. The important points were highlighted.

It was explained in coherent manner.

The symptamology are clearly listed.

Pictures are given clearly about investigation.

Complete drug history and treatment is not clearly given.

Patient centered data around the theme of renal failure patients with AKI, CKD and acute on CKD, 

captured by students from 2016 and 2019 batch in the links below:

Patients with low back ache and renal failure :

AKI :

https://laharikantoju.blogspot.com/2021/07/58-year-old-male-patient-elog-lahari.html?m=1 

Acute on CKD :

http://srinaini25.blogspot.com/2021/07/srinaini-roll-no-33-3rd-semester-this.html

CKD :

https://krupalatha54.blogspot.com/2021/07/a-49-yr-old-female-with-generalized.html?m=1

Patient with coma and renal failure  :

https://ananyapulikandala106.blogspot.com/2021/06/a-35yr-old-female-elog.html

https://pallavi191.blogspot.com/2021/06/gm-cases_30.html?m=1

Patients with acute on CKD :

https://kavyasamudrala.blogspot.com/2021/05/medicine-case-discussion-this-is-online.html?m=1

https://rishikakolotimedlog.blogspot.com/2021/07/45-year-old-male-with-chief-complains.html?m=1

https://krupalatha54.blogspot.com/2021/06/this-is-online-e-log-book-to-discuss.html?m=1

Patients with AKI :

https://keerthireddy42.blogspot.com/2021/07/43-yr-old-male-of-nalgonda-came-to.html?m=1

https://casescape.blogspot.com/2021/06/acute-kidney-injury-secondary-to.html?m=1

http://chavvaclassworkdecjan.blogspot.com/2021/06/pancreatitis-in-chronic-alcoholic-with.html?m=1

QUESTION-2:-

Share the link to your own case report of a patient that you connected with and engaged while capturing his her sequential life events before and after the illness and clinical and investigational images along with your discussion of that case. 

ANSWER-2

I did not get a chance to take up any case.

QUESTION-3

Please go through the cases in the links shared above and provide your critical appraisal of the captured data in terms of completeness, correctness and ability to provide useful leads to analyze the diagnostic and therapeutic uncertainties around the cases shared.

ANSWER-3

CASE-1:

Evolution of symptoms were very well presented. Explanation for every treatment and causes were written in a very coherent manner.Overall it was very well explained and easy to understand.

CASE-2:

The history taking of the patient was written so orderly manner.It would have been better if more pictures were given directly which would make it easier to understand the context.

CASE-3:

The case was very well presented and explained.All the keywords were highlighted which made it easier to get the concept and the mechanisms of treatment and the case were very well explained.The histolgy information regarding the case made it easy to understand.                        

CASE-4:

It has been elaborated in very good manner. The main points have been highlighted clearly.The pictures of investigation are posted in the elog which made it easier to follow up the case.The timely updates were also mentioned.

CASE-5:

The explanation was good, but the certain points could have been highlighted.                  If a summary of patients details is given which made it much easier to understand.

CASE-6:

Very clean presentation and very well explained.It was easy to understand.                Can add some more details about terapautic investigations.

CASE-7:

The summary of the patient was mentioned which made it easier to understand.The presentation was neat, but certain points can be elaborated.The links were attached from where the info was collected.The important words were highlited which made easier to understand the case.

CASE-8:

The patient history could have been elaborated to understand the case even more easily.The discharge summary was not given. Other than that everything is nicely presented.The scan reports were attached in orderly manner and time is mentioned regarding the investigation which is good.

CASE-9:

The patients case has been summarized it is easily understandable,the presentation was very neat and easy to understand.Main points were highlighted.The time line events were posted with progress of patient's symptoms which is very well done.

CASE-10:

The case is presented well.The time line graph of vitals had helped to understand his progress clearly.Time line of laboratory  investigations is give.This made me easy to understand whether he is reacting and getting better with the the medications given to him.

CASE-11:

The case was presented well.The summary at the end was a good idea it end with.The laboratory investigations well presented in coherent manner.

QUESTION-4

Please analyze the above linked patient data by first preparing a problem list for each patient (based on the shared data) and then discuss the diagnostic and therapeutic uncertainty around solving those problems. Also include the review of literature around sensitivity and specificity of the diagnostic interventions mentioned and same around efficacy of the therapeutic interventions mentioned for each patient. 

ANSWER-4

CASE-1:

Problem list:

•lower back ache 

•burning micturition

•Fever with chills

•trauma to head

•mild hepatomegaly with grade 1 fatty liver

•high serum creatinine

•high blood urea

•pus cells in urine

Solution:

1)IVF : -RL  @ UO+ 30ml/hr

            -NS

2)SALT RESTRICTION  < 2.4gm/day

3)INJ    TAZAR    4.5gm  IV/TID

                             2.25gm IV/ TID

4)INJ     PANTOP 40mg  IV/OD

5)INJ     THIAMINE  1AMP  IN  100ml   NS   IV/TID

6)INJ     HAI  S/C  ACC  TO   SLIDING SCALE

              8AM  -  2PM  -  8PM

7)SYP    LACTULOSE   15ml    PO/TID [ To maintain stools less than or equal to 2]

8) GRBS  - 6th Hourly

9) BP/PR/TEMP - 4th Hourly

10) I/O - CHARTING

ON 10/7/21 :

1)IVF : -RL  @ UO+ 30ml/hr

            -NS

2)SALT RESTRICTION  < 2.4gm/day

3)INJ    TAZAR     2.25gm IV/ TID

4)INJ     PANTOP 40mg  IV/OD

5)INJ     THIAMINE  1AMP  IN  100ml   NS   IV/TID

6)TAB.   PCM   500mg    PO/ SOS

7)INJ     HAI  S/C  ACC  TO   SLIDING SCALE

              8AM  -  2PM  -  8PM

8)INFORM  GRBS 

9)GRBS  - 6th Hourly

10) BP/PR/TEMP - 4th Hourly

11) I/O - CHARTING (STRICT)

12)T. ULTRACET  PO 1/2 TAB  QID

-Foley's removed,

13)INPUT   UPTO   2 Liters only

CASE-2:

•lower back ache

•Dribble of urine

•Pedal edema

•High blood urea

•High serum creatinine

•Anemia

•Spondylodiscitis

•Tremours

Solution:

13/7/21

• IVF -    NS-0.9%  @100ml/hr

• Inj. Tazar 2.25gm I.V -TID 

• Inj. Lasik 40mg I.V -BD 

•Nebulization Salbutamol -4th hourly 

• Inj. Pantop 40mg I.V -OD 

• Tab. PCM 650mg -TID 

• Foleys catheterization 

• Temperature ,Bp, PR Charting  hourly 

• Strict IO Charting

•GRBS -12th hourly 

• Inj.25% D with 10units of insulin IV -slow for 1hr 

14/7/21

• IVF -NS  0.9% & DNS  -continous infusion @100ml/hr
• Inj.Piptaz 2.25gm I.V -TID
• Inj.Lasix 40mg I.V -BD
• Inj.Pantop 40mg I.V -OD
• Nebulization budecort -8th hourly 
• T.PCM 650mg -TID
• INJ. Neomol 1mg -I.V -SOS 
• Temperature charting 4th hourly 
• Monitor Bp,PR 
• Left U/l elevation 
• strict I/O charting 
• Nebulization Salbutamol 2 repluses -6th hourly 
• INJ. MAI 10u in 25% D over 45min I.V 

15/7/21
• IVF -NS 0.9% &DNS U.O + 30ml/hr
• Inj. PIPTAZ 2.25gm -I.V -TID
• Inj.Lasix 40mg I.V -BD
• Inj.Pantop 40mg I.V -OD
• Nebulization Salbutamol 2 repluses -6th hourly 
• T.PCM 650mg TID-after checking Temp.
• Temperature charting 4th hourly 
• Monitor Bp,PR 
• strict I/O charting 
• Syp. Mucaine gel 10ml -BD 


16/7/21
• IVF -NS 0.9% &DNS U.O + 30ml/hr
• Inj. PIPTAZ 2.25gm -I.V -TID
• Inj.Lasix 40mg I.V -BD
• Oral fluids upto 2-3liters/day 
• Monitor Bp,PR ,Temperature 
• strict I/O charting 
• Limb elevation- Crepe bandage 
• Syp.mucaine gel 15ml -TID 


17/7/21
• Inj. PIPTAZ 2.25gm -I.V -TID
• Inj.Pantop 40mg I.V -OD
• Syp.mucaine gel 15ml -TID 
• Limb elevation- Crepe bandage 
• Monitor Bp,PR ,Temperature ,spo2%
• Tab.Febuxostat 40mg -OD
• Inj.Optinueron 1 ampule in 100ml NS /I.V/ OD 

18/7/21
• Inj. PIPTAZ 2.25gm -I.V -TID
• Inj.Pantop 40mg I.V -OD
• Inj.Optinueron 1 ampule in 100ml NS /I.V/ OD 
• Syp.mucaine gel 15ml -TID 
• Limb elevation- Crepe bandage 
• Monitor Bp,PR ,Temperature ,spo2%
• Tab.Febuxostat 40mg -OD
• Oral fluids upto 2-3L/day 

19/7/21
• Inj. PIPTAZ 2.25gm -I.V -TID
• Inj.Pantop 40mg I.V -OD
• Inj.Optinueron 1 ampule in 100ml NS /I.V/ OD 
• Syp.mucaine gel 15ml -TID 
• Limb elevation- Crepe bandage 
• Monitor Bp,PR ,Temperature ,spo2%
• Tab.Febuxostat 40mg -OD
• Oral fluids upto 2-3L/day

 

20/7/21

• Tab.Pantop 40mg  -OD
• Tab.Febuxostat 80mg -OD
• Tab.Neurobion forte -OD 
• Syp.mucaine gel 15ml -TID 
• Limb elevation- Crepe bandage 
• Monitor Bp,PR ,Temperature ,spo2
• Oral fluids upto 2-3L/day 

21/7/21
• Tab.Pantop 40mg  -OD
• Tab.Febuxostat 80mg -OD
• Tab.Neurobion forte -OD 
• Syp.mucaine gel 15ml -TID 
• Limb elevation- Crepe bandage 
• Monitor Bp,PR ,Temperature ,spo2
• Oral fluids upto 2-3L/day
• Inj.Ciprofloxacin 500mg-OD 

22/7/21
• Inj. Ciprofloxacin 500mg-OD
• Tab.Febuxostat 40mg -OD
• Tab.Neurobion forte -OD 
• Tab.pantop 40mg-OD
• Syp.mucaine gel 15ml -TID 
• Limb elevation- Crepe bandage 
• Monitor Bp,PR ,Temperature ,spo2
• Oral fluids upto 2-3L/day

•Tab.Ultracet 1/2 tab.-QID

CASE-3:-

Problem list:

•Haemorrhoids

•Muscle aches

•Fever

•Generalized weekness

•Vomiting

•Pedal oedema

•Dimorphic anaemia

•High serum creatinine

•High blood urea

•Multiple myeloma

Solution:-

 on 9/07/2021

- T. PAN 40mg /PO / OD

- oral fluids upto 1.5 - 2 lit / day

- Protein - x ( plant based ) 2 tablespoon   in 1 glass of  milk  

- Donot give IV fluids unless instructed

- T. ZOFER 4mg / PO / SOS

- Evaluate Anaemia start Iron Supplementation (oral ) after Gastritis ( (resolved )

- TAB NODOSIS  550 BD

10/07/2021

- oral fluids upto 1.5 - 2 lit / day 

- T. PAN 40mg /PO / OD 

-  T. ZOFER 4mg / PO /SOS 

- TAB NODOSIS  550 mg / PO/BD 

- Protein - x ( plant based ) 2 tablespoon   in 1 glass of  milk 

- I/O charting

- BP / PR / Temp  - 4th Hrly 

- Neb c Duoun 2 respules 8th hrly

★11/7/2021 

- oral fluids upto 1.5 - 2 lit / day 

- Tab PAN-D  PO/OD ( 8AM)

- T. ZOFER 4mg / PO /SOS 

- TAB NODOSIS  550 mg / PO/BD 

- Protein - x ( plant based ) 2 tablespoon in 1 glass of milk 

- Inj ERYTHROPOIETIN 4000IVS/C weekly twice 

- BP / PR / Temp  - 4th Hrly  

- T. OROFER - XT PO/BD 

- Inj OPTINEORON 1 AMO IN 500ml NS IV/OD 

- IVF -NS  UO +30ml/hr 

          - RL 

- I/O - CHARTING 

★12/7/21

-inj.optineuron 1 amp in 500ml NS IV/OD

-ivf. NS RL @ uo + 30 ml/hr

-inj. erytropoitin 4000 iv s/c weekly twice

-tab.pan-d po/od (8 am)

-tab.orofer-xt PO/BD

-tab.nodosis 500mg PO/BD

-protein- x powder 2 tsp in 1 glass of milk PO/TID

-tab. zofer 4mg PO/sos

-BP/PR/Temp - 4th hrly

- I/o - charting 

★13/7/2021

- Inj.optineuron 1 amp in 500ml NS SLOW/ IV/OD

-tab. pantop 40 mg RO/OD

-tab.nodosis 500mg PO/BD

-Protein- x powder 2 tsp in 1 glass of milk PO/TID

-I/o charting 

- T.OROFER  XT/OD

14/07/2021

- Inj.optineuron 1 amp in 500ml NS SLOW/ IV/OD

-tab. pantop 40 mg RO/OD

-tab.nodosis 500mg PO/BD

-Protein- x powder 2 tsp in 1 glass of milk PO/TID

-I/o charting 

- T.OROFER  XT/OD

CASE-4:-

•Problem list:

•Fever

•Diarrhea

•Back pain

•Diabetes mellitus type 2

•Vomiting

•Loose stools

•Metabolic acidosis

•Bed sores

•Left kidney increase in size

•Acute polynephritis

Solution:-

Ventilator

Dialysis

Physiotherapy

Treatment for sores

Day 1

Inj. NORAD 2amp in 50ml NS

Inj. PIPTAZ 2.25gm.

Inj. DOPAMINE 2amp in 50ml

Inj. HAI 1ml in 39ml NS

 

Day 2 

Inj.HAI 1ml in 39mlNS

Inj. PIPTAZ 2.25gm.

Inj. CLEXANE 40gm. 

Iv infusion NS RL @100ml/hr.

Day 3 

Inj.HAI 1ml + 34ml NS

Inj. PIPTAZ 2.25gm

Iv infusion NS (urine output + 40ml/hr)

Inj. NORADRENALINE(2 amp+46ml NS) 

  

Day 4,5 same as day 3

Day 6

Inj. PIPTAZ

Inj. LEVOFLOX

Inj. VANCOMYCIN

Day 7 and 8 same as day 6.

Day 9

Inj. MEROPENEM

Inj. LEVOFLOX

Inj.VANCOMYCIN

Day 10 and 11 same as day 9

Day 12

Inj. MEROPENEM

Inj. FOSFOMYCIN

Inj. CLEXANE

Day 13 and day 14 same treatment as of day 12 additionally Inj. LASIX was given. 

CASE-5:-

Problem list:-

•Diabetes mellitus type 2

•Hepatic encephalopathy grade2

•Abdominal distension

•Pedal edema grade 2

•Pus cells in urine

•Anemia

•Abnormal increase in urea in urine

•Increase in levels of alakaline phosphate

•Multiple acute infarcts in bilateral cerbral and Cerebellar hemispheres

Solution:-

Day 1:

1. Inj. Monocef 1gm IV/BD

2. Inj. Vancomycin 500mg IV/BD in 100ml NS over 1hr

3. Procto clysis enema

4. Inj. Pan 40 mg Iv/OD

5. Inj. Thiamine 200mg in 100ml NS /BD

6. Inj. HAI 6U S/C TID

Day 2&3:

Same treatment followed

Day 4:

Same treatment followed except Inj. Monocef.

Inj. Augmentin 1.2 gm IV/TID

Tab. Ecospirn 150mg PO/HS/SOS

Tab. Clopidogrel 75mg PO/HS/SOS

Tab. Atorvas 20mg PO/HS/OD added

Advice at Discharge:

1. Inj. Vancomycin 500mg IV/BD in 100ml NS over 1hr

2. Inj. Pan 40 mg Iv/OD

3. Inj. Thiamine 200mg in 100ml NS /BD

4. Inj. HAI 6U S/C TID

5. Inj. Augmentin 1.2 gm IV/TID

6. Tab. Ecospirn 150mg PO/HS/SOS

7. Tab. Clopidogrel 75mg PO/HS/SOS

8. Tab. Atorvas 20mg PO/HS/OD added

CASE-6:-

Problem list:-

•Fever 

•Pus in Urine

•Prostomegaly

•Hypnoatremia

•High creatinine levels

•High grade fever with chills and rigor

•Anemia

•Bilateral hydroureteronephrosis more on right 

•Urinary bladder with diffuse circumferential wall thickness

•Phlebolith

Solution:-

Injection PANTOP 40mg IV/OD

Injection PIPTAZ  4.5 stat  and 2.25 gm  IV/ TID

Injection LASIX 40mg IV/BD

Injection optineuron 1AMP in 100ml NS slow IV/OD

Injection NEDMOL 100ml IV/SOS

Tab PCM 650mg TID

Insulin Human actrapid - 16 IU/TID

CASE-7:-

Problem list:-

•Shortness of breath

•Deranged RFT

•Chronic renal failure

•Orthopnea

•Diabetes mellitus type 2

•Hypertension

•Edema

•Hemoglobin level less

Solution:-

1. TAB. BISOPROLOL 5mg OD
2.TAB. NITROHART 20/37.5mg 1/2 T/D
3.TAB NICARDIA XL 30mg OD
4.TAB. GLICIAZIDE 80mg BD
5.TAB. NODOSIS 500 mg TD
6.Cap. BIO-D3 OD
7.Cap. GEMSOLINE OD
8.TAB. ECOSPRIN-AV 150/20mg OD
9.TAB.LASIX 40mg BD
10. SYP. LACTULOSE 15ml

CASE-8:-

Problem list:-

•Pedal edema

•Loose stools

•Vomitings

•Pneumonitis with time 1

•Grade 1 fatty liver

•Increased serum creatinine

•Increased blood urea

•Right heart failure

Solution:-

1. IV fluids

2. Tab. Pan 40 mg po OD 

3. Inj. Lasix 80 mg IV BD

4. Thiamin 200 mg in 100 ml NS IV BD

5.Tab. Levocet 5 mg Po BD

6.Liquid paraffin for LIA

7.Grbs 6 th hrly

8.I/o charting, temp.charting

CASE-9:-

Problem list:-

•Loose stools

•Abdominal distension

•Pedal edema

•Alcoholic hepatitis

Solution:-

• INJ THIAMINE 100 mg in 100 ml NS slow IV / TID
• INJ OPTINEURON 1AMP in 100 ml NS slow IV / OD
• INJ LASIX 40 mg
• TAB. ALDACTONE 50 mg PO / BD
• INJ PANTOP 40 mg IV/ OD
• ABDOMINAL GIRTH MEASUREMENT DAILY
• BP /PR/TEMP/ RR -4 hourly 
• I/O CHARTHING

On 06/07/2021  : 

1)PLENTY OF ORAL FLUIDS 

2)INJ.METROGYL 400mg /IV/TID 

3)INJ .CIPROFLOX 500mg /IV//OD 

4)INJ.PANTOP 40mg iv/OD

5)INJ.THIAMINE 1amp in 100ml NS IV/TID 

6)INJ.OPTINEURON 1ampin 100ml NS IV/od

7)TAB .SPORLAC DS PO/TID 

8)ORS SACHET 1 in 1L OF WATER 

9)TAB LOPERAMIDE.  2mg /po / SOS

10)BP/PR/TEMP/ RR 4 th hrly 

11)I/O CHARTING.  

On 07/07/2021 :

1. PLENTY OF ORAL FLUIDS 
2. INJ.METROGYL 400mg /IV/TID 
3. INJ .CIPROFLOX 500mg /IV//OD 
4. INJ.PANTOP 40mg iv/OD 
5. INJ.THIAMINE 1amp in 100ml NS IV/TID 
6. INJ.OPTINEURON 1ampin 100ml NS IV/od
7. TAB .SPORLAC DS PO/TID 
8. ORS SACHET 1 in 1L OF WATER 
9. TAB LOPERAMIDE.  2mg /po / Sos
10. BP/PR/TEMP/ RR 4 th hrly 
11. I/O CHARTING.  

On 08/07/2021 

1)PLENTY OF ORAL FLUIDS 

2)INJ.METROGYL 400mg /IV/TID 

3)INJ .CIPROFLOX 500mg /IV//OD 

4)INJ.PANTOP 40mg iv/OD

5)INJ.THIAMINE 1amp in 100ml NS IV/TID 

6)INJ.OPTINEURON 1ampin 100ml NS IV/od

7)TAB .SPORLAC DS PO/TID 

8)ORS SACHET 1 in 1L OF WATER 

9)TAB LOPERAMIDE.  2mg /po / SOS

10)BP/PR/TEMP/ RR 4 th hrly 

11)I/O CHARTING.  

  *12)TAB ECOSPIRIN 75mg/po/od 

 On 09/07/2021 :

1)PLENTY OF ORAL FLUIDS 

2)INJ.METROGYL 400mg /IV/TID 

3)INJ .CIPROFLOX 500mg /IV//OD 

4)INJ.PANTOP 40mg iv/OD

5)INJ.THIAMINE 1amp in 100ml NS IV/TID 

6)INJ.OPTINEURON 1ampin 100ml NS IV/od

*7)TAB LORAZEPAM 2mg OD 

8)ORS SACHET 1 in 1L OF WATER 

*9)TAB ECOSPORIN 75 mg OD 

10)BP/PR/TEMP/ RR 4 th hrly 

11)I/O CHARTING. 

On 10/07/2021 :

1)PLENTY OF ORAL FLUIDS 

2)TAB PANTOP 40mg iv/OD

3)INJ.THIAMINE 1amp in 100ml NS IV/TID 

4)INJ.OPTINEURON 1ampin 100ml NS IV/od

5)TAB ECOSPORIN 75 mg OD 

6)TAB LORAZEPAM 2mg OD

7)BP/PR/TEMP/ RR 4 th hrly 

8)I/O CHARTING 

On 11/07/2021 :

1)PLENTY OF ORAL FLUIDS 

2)TAB PANTOP 40mg iv/OD

3)INJ.THIAMINE 1amp in 100ml NS IV/TID 

*4)TAB NEUROBION FORTE OD 

5)TAB ECOSPORIN 75 mg OD 

6)TAB LORAZEPAM 2mg OD 

6)BP/PR/TEMP/ RR 4 th hrly 

7)I/O CHARTING. 

On 12/07/2021 

1)FLUID RESTRICTION <1.5L/ day 

SALT RESTRICTION <2gm/day

2)Tab PAN 40mg iv/OD

*3)TAB. BENFOMETPLUS OD 

*4)TAB NEUROBION FORTE OD 

5)TAB ECOSPORIN 75 mg OD 

*6)TAB LIVOGEN OD 

*7)INJ. VITCOFOL 500mg IM/OD 

*8)TAB. LASIX 20mg OD 

*9)TAB. RIFAXIMINE 550mg BD 

6)BP/PR/TEMP/ RR 4 th hrly 

7)I/O CHARTING. 

CASE-10:-

Problem list:-

•Pedal edema pitting type

•Fever

•Diabetes mellitus

•Acute kidney injury secondary to urosepsis

•Shortness of breath

•Increased serum creatinine

•Increased blood urea

•Hemoglobin lower than normal

Solution:-

15/06/21:

• Inj LASIX 40mg (8am- 2pm -8pm)
• IVF - NS @ UO + 50 ml/hr

16/6/21

•  Inj LASIX 40 mg IV/TID          1 -1 - 1
•  IVF - NS @ UO + 50 ml/hr
•  Inj MAGNEXFORTE 1.5 gm/IV/BD
•  Tab NODOSIS - XT PO/OD
•  Inj HAI s/c
•  Neb plain Asthalin 4 respules    [ 1 - 1 - 1 - 1 ]

17/6/21

•  Inj LASIX 40 mg IV/TID    1 -1 - 1
•  IVF - NS @ UO + 50 ml/hr
•  Inj MAGNEXFORTE 1.5 gm/IV/BD
•  Tab NODOSIS - XT  PO/OD
•  Tab OROFEA - XT  PO/OD
•  Inj HAI s/c
•  Neb plain Asthalin 2 respules
•  Strict I/O charting

18/6/21

•  Inj LASIX 40 mg IV/TID   1 -1 - 1
•  IVF - NS @ UO + 50 ml/hr
•  Inj MAGNEXFORTE 1.5 gm/IV/BD
•  Tab NODOSIS - XT  PO/OD
•  Tab OROFEA - XT  PO/OD
•  Inj HAI s/c
•  Neb plain Asthalin 2 respules  QID
•  Strict I/O charting
• Tab ULTRACET 1/2 tab QID [ 1/2 - 1/2 - 1/2 - 1/2 ]

19/6/21

•  Inj LASIX 40 mg IV/TID    1 -1 - 1
•  IVF - NS @ UO + 50 ml/hr
•  Inj MAGNEXFORTE 1.5 gm/IV/BD
•  Tab NODOSIS - 500 mg  PO/OD
•  Tab OROFEA - XT  PO/OD
•  Inj HAI s/c
•  Neb plain Asthalin 2 respules  QID
•  Strict I/O charting
•  Tab ULTRACET 1/2 tab QID[ 1/2 - 1/2 - 1/2 - 1/2 ]

20/6/21

•  Inj LASIX 40 mg IV/TID [ 1 -1 - 1 ]
•  IVF - NS @ UO + 50 ml/hr
•  Inj MAGNEXFORTE 1.5 gm/IV/BD
•  Tab NODOSIS - 500 mg PO/OD
•  Tab OROFEA - XT PO/OD
•  Inj HAI s/c
•  Neb plain Asthalin 2 respules QID
•  Strict I/O charting
•  Tab ULTRACET 1/2 tab QID[ 1/2 - 1/2 - 1/2 - 1/2 ]
•  BP/PR/SO2/Temperature monitoring
•  GRBS charting

21/6/21

•  Inj LASIX 40 mg IV/TID [ 1 -1 - 1 ]
•  IVF - NS @ UO + 50 ml/hr
•  Inj MAGNEXFORTE 1.5 gm/IV/BD
•  Tab NODOSIS - 500 mg PO/OD
•  Tab OROFEA - XT PO/OD
•  Inj HAI s/c TID  [ 10U - 8U - 8U ]
•  Neb plain Asthalin 2 respules QID
•  Tab Norflox 200 mg PO/BD
•  Tab ULTRACET 1/2 tab QID[ 1/2 - 1/2 - 1/2 - 1/2 ]
•  BP/PR/SO2/Temperature monitoring
•  GRBS charting
•  Strict I/O charting

22/6/21

•  Inj LASIX 40 mg IV/TID [ 1 -1 - 1 ]
•  IVF - NS @ UO + 50 ml/hr
•  Tab Norflox 200 mg PO/BD
•  Ing OPTINEURON 1amp in 100 ml  NS IV/OD
•  Tab OROFEA - XT PO/OD
•  Tab SHELCAL-CT PO/OD
•  Inj HAI s/c TID [ 10U - 8U - 8U ]
•  Tab ULTRACET 1/2 tab QID[ 1/2 - 1/2 - 1/2 - 1/2 ]
•  BP/PR/SO2/Temperature monitoring
•  GRBS charting
•  Strict I/O charting

23/6/21

•  Inj LASIX 40 mg IV/TID [ 1 -1 - 1 ]
•  Tab Norflox 200 mg PO/BD
•  Tab ULTRACET 1/2 tab QID[ 1/2 - 1/2 - 1/2 - 1/2 ]
•  Tab OROFEA - XT PO/OD
•  Tab SHELCAL-CT PO/OD
•  Inj HAI s/c TID [ 10U - 8U - 8U ]
•  BP/PR/SO2/Temperature monitoring
•  GRBS charting
•  Strict I/O charting

CASE-11:-

Problem list:-

•pain in abdomen in epigastric redion 

•Vomiting 

•Increased serum creatinine levels

•Pedal edema pitting type

•Distended abdomen

•Tremors

•Acute pancreatitis

Solution:-

Dialysis is done to correct serum creatinine levels and urea levels

 Iv fluids : NS 40 ml /hr.

IV lasix  40 mg BD .

Tab Nodosis .

IV PIPTAZ 4.5 Gms. BD 

Iv 25%Dextrose. 100 ml BD 

Tab . Nicardia 10 mg  TID.

D A Y  W I S E  U P D A T E S: 

Day 1and 2 =Urine output 1500ml, 

       Fluid intake 3000ml

QUESTION-5

Reflective logging  of one's own experiences is a vital tool toward competency development in medical education and research. 

ANSWER-5

In the midst of the pandemic medical school taking the online approach which is primarily a practical sector. This is the educational set up where doctors interact with the patients and try to gather history and knowledge and try to provide their expertise. But still our medical schools are working and they have brought the clinical rotation for which we had always as a medical student being excited about right in front of our mobile/laptop screens. The general medicine faculty have been doing great and also are helping us to acquire knowledge and helped us learn to use the Internet and motivate us to read research papers and old cases about a topic. This has been a great learning session for all of us , looking forward to attend the clinical postings in the hospital.

PATHOLOGY ASSIGNMENT

SOFT TISSUE TUMORS

     (Roll no  135-139)

135-UMR.AKANKSHA

(WHO classification of soft tissue tumours)

136-DEDEEPYA VEMURI

(Etiopaghogenesis of soft tissue tumours)

137-UJWALA

(Gross features of soft tissue tumours)

138-VAGISHA RANI

(Microscopy of soft tissue tumours)

139-VAMSHITHA

(Genetics of soft tissue tumours)

Topic-1

World Health Organization classification of soft-tissue tumors 

 The World Health Organization (WHO) issued an updated classification of soft-tissue tumors that divided them into the following categories.

• Adipocytic tumors
• Fibroblastic/myofibroblastic tumors
• So-called fibrohistiocytic tumors
• Smooth-muscle tumors
• Pericytic (perivascular) tumors
• Skeletal-muscle tumors
• Vascular tumors
• Chondro-osseous tumors
• Gastrointestinal stromal tumors
• Nerve-sheath tumors
• Tumors of uncertain differentiation
• Undifferentiated/unclassified sarcomas

In addition, as part of this classification, soft tissue tumors were divided into the following four categories as appropriate:

• Benign
• Intermediate (locally aggressive)
• Intermediate (rarely metastasizing)
• Malignant

This terminology should not be confused with the grading system mentioned above, in which grade 2 may be regarded as intermediate.

Adipocytic tumors

Benign adipocytic tumors include the following:

• Lipoma
• Lipomatosis
• Lipomatosis of nerve
• Lipoblastoma/lipoblastomatosis
• Angiolipoma
• Myolipoma
• Chondroid lipoma
• Extrarenal angiomyolipoma
• Extra-adrenal myelolipoma
• Spindle cell/pleomorphic lipoma
• Hibernoma

Intermediate (locally aggressive) adipocytic tumors include the following:

• Atypical lipomatous tumor/well-differentiated liposarcoma

Malignant adipocytic tumors include the following:

• Dedifferentiated liposarcoma
• Myxoid liposarcoma
• Pleomorphic liposarcoma
• Liposarcoma, not otherwise specified

Fibroblastic/myofibroblastic tumors

Benign fibroblastic/myofibroblastic tumors include the following:

• Nodular fasciitis
• Proliferative fasciitis
• Proliferative myositis
• Myositis ossificans
• Fibro-osseous pseudotumor of digits
• Ischemic fasciitis
• Elastofibroma
• Fibrous hamartoma of infancy
• Fibromatosis colli
• Juvenile hyaline fibromatosis
• Inclusion body fibromatosis
• Fibroma of tendon sheath
• Desmoplastic fibroblastoma
• Mammary-type myofibroblastoma
• Calcifying aponeurotic fibroma
• Angiomyofibroblastoma
• Cellular angiofibroma
• Nuchal-type fibroma
• Gardner fibroma
• Calcifying fibrous tumor

Intermediate (locally aggressive) fibroblastic/myofibroblastic tumors include the following:

• Superficial fibromatoses - Palmar/plantar
• Desmoid-type fibromatoses
• Lipofibromatosis
• Giant cell fibroblastoma

Intermediate (rarely metastasizing) fibroblastic/myofibroblastic tumors include the following:

• Dermatofibrosarcoma protuberans - Fibrosarcomatous, pigmented
• Solitary fibrous tumor - Solitary fibrous tumor, malignant
• Inflammatory myofibroblastic tumor
• Low-grade myofibroblastic sarcoma
• Myxoinflammatory fibroblastic sarcoma/atypical myxoinflammatory fibroblastic tumor
• Infantile fibrosarcoma

Malignant fibroblastic/myofibroblastic tumors include the following:

• Adult fibrosarcoma
• Myxofibrosarcoma
• Low-grade fibromyxoid sarcoma
• Sclerosing epithelioid fibrosarcoma

So-called fibrohistiocytic tumors

Benign tumors of this type include the following:

• Tenosynovial giant cell tumor - Localized, diffuse, malignant
• Deep benign fibrous histiocytoma

Intermediate (rarely metastasizing) tumors of this type include the following:

• Plexiform fibrohistiocytic tumor
• Giant cell tumor of soft tissues

Smooth-muscle tumors

These tumors include the following:

• Benign - Leiomyoma of deep soft tissue
• Malignant - Leiomyosarcoma (excluding skin)

Pericytic (perivascular) tumors

These tumors include the following:

• Glomus tumor (and variants) - Glomangiomatosis, malignant glomus tumor
• Myopericytoma - Myofibroma, myofibromatosis
• Angioleiomyoma

Skeletal-muscle tumors

These tumors include the following:

• Rhabdomyoma
• Embryonal rhabdomyosarcoma
• Alveolar rhabdomyosarcoma 
• Pleomorphic rhabdomyosarcoma
• Spindle cell/sclerosing rhabdomyosarcoma

Vascular tumors

Benign vascular tumors include the following:

• Hemangioma - Synovial, venous, arteriovenous hemagnioma/malformation
• Epithelioid hemangioma
• Angiomatosis
• Lymphangioma

Intermediate (locally aggressive) vascular tumors include the following:

• Kaposiform hemangioendothelioma

Intermediate (rarely metastasizing) vascular tumors include the following:

• Retiform hemangioendothelioma
• Papillary intralymphatic angioendothelioma
• Composite hemangioendothelioma
• Pseudomyogenic (epithelioid sarcoma-like) hemangioendothelioma
• Kaposi sarcoma

Malignant vascular tumors include the following:

• Epithelioid hemangioendothelioma
• Angiosarcoma of soft tissue

Chondro-osseous tumors

These tumors include the following:

• Soft-tissue chondroma
• Mesenchymal chondrosarcoma
• Extraskeletal osteosarcoma

Gastrointestinal stromal tumors

Gastrointestinal stromal tumors (GISTs) include the following:

• Benign GIST
• GIST of uncertain malignant potential
• Malignant GIST

Nerve-sheath tumors

Benign nerve-sheath tumors include the following:

• Schwannoma (including variants)
• Melanotic schwannoma
• Neurofibroma (including variants) - Plexiform neurofibroma
• Perineurioma - Malignant perineurioma
• Granular cell tumor
• Dermal nerve sheath myxoma
• Solitary circumscribed neuroma
• Ectopic meningioma
• Nasal glial heterotopia
• Benign Triton tumor
• Hybrid nerve-sheath tumors

Malignant nerve-sheath tumors include the following:

• Malignant peripheral nerve sheath tumor
• Epithelioid malignant nerve sheath tumor
• Malignant Triton tumor
• Malignant granular cell tumor
• Ectomesenchymoma

Tumors of uncertain differentiation

Benign tumors of uncertain differentiation include the following:

• Acral fibromyxoma
• Intramuscular myxoma (including cellular variant)
• Juxta-articular myxoma
• Deep ("aggressive") angiomyxoma
• Pleomorphic hyalinizing angiectatic tumor
• Ectopic hamartomatous thymoma

Intermediate (locally aggressive) tumors of uncertain differentiation include the following:

• Hemosiderotic fibrolipomatous tumor

Intermediate (rarely metastasizing) tumors of uncertain differentiation include the following:

• Atypical fibroxanthoma
• Angiomatoid fibrous histiocytoma
• Ossifying fibromyxoid tumor - Including malignant
• Mixed tumor NOS - Including malignant
• Myoepithelioma
• Myoepithelial carcinoma
• Phosphaturic mesenchymal tumor - Benign, malignant

Malignant tumors of uncertain differentiation include the following:

• Synovial sarcoma NOS - Spindle cell, biphasic
• Epithelioid sarcoma
• Alveolar soft-part sarcoma
• Clear cell sarcoma of soft tissue
• Extraskeletal myxoid chondrosarcoma
• Extraskeletal Ewing sarcoma
• Desmoplastic small round cell tumor
• Extrarenal rhabdoid tumor
• Neoplasms with perivascular epithelioid cell differentiation (PEComa)
• Intimal sarcoma

Undifferentiated/unclassified sarcomas

These tumorsinclude the following:

• Undifferentiated spindle cell sarcoma
• Undifferentiated pleomorphic sarcoma
• Undifferentiated round cell sarcoma
• Undifferentiated epithelioid sarcoma
• Undifferentiated sarcoma NOS

Benign vs intermediate vs malignant tumors

Benign soft-tissue tumors usually do not recur locally, and if they do, the recurrence is nondestructive and almost always readily curable by complete local excision. Morphologically benign lesions, which are extremely rare, may give rise to distant metastases, which cannot be predicted on the basis of routine, contemporary histologic evaluation. This is best documented in rare, cutaneous benign fibrous histiocytoma.

Intermediate (locally aggressive) soft-tissue tumors show an infiltrative and locally destructive growth pattern. However, although they may recur locally, they do not metastasize. They usually require excision with a wide margin of normal tissue for better local control. The example in this category is desmoid (fibromatosis).

Intermediate (rarely metastasizing) soft-tissue tumors are often locally aggressive, but in some cases, they also have a tendency to produce distant metastases (usually in a lymph node or lung). This risk is low (< 2%), but histomorphologically, it is not reproducibly predictable. The classic examples in this group are plexiform fibrohistiocytic tumor and angiomatoid fibrous histiocytoma.

Malignant soft-tissue sarcomas are locally destructive with the potential to recur. The risk of distant metastasis is significant. (Depending on histologic type and grade, the potential ranges from 20% to almost 100%). Histologically low-grade sarcomas have a lower chance of metastasis (only 2-10%). However, the recurrences of such tumors may advance in grade and attain a higher risk of metastatic potential similar to that associated with myxofibrosarcoma and leiomyosarcoma.

TOPIC-2

ETIOPATHOGENESIS OF SOFT TISSUE TUMORS

Most sarcomas are sporadic and have no known predisposing cause.  

A small minority are associated with germline mutations in tumor suppressor genes.

Others are linked to environmental exposures such as radiation, burns, or toxins.

Etiology of soft tissue tumours remains largely unknown.

1. Frequently there is history of antecedent trauma which may bring the tumour to attention of the patient. 

2. Molecular and cytogenetic studies in many soft tissue tumours reveal chromosomal abnormalities and mutations in genes which can be used as a marker for diagnosis and histogenesis  e.g. translocations, various fusion genes etc.

3. Most of the soft tissue tumours occur sporadically;however, there are a few examples which are components of syndromes e.g. neurofibromatosis type 1, Li-Fraumeni syndrome, Osler-Weber-Rendu syndrome etc.

The genetics of tumorogenesis are heterogenous, but some generilizations can be made based on karyotypic complexity:

SIMPLE KARYOTYPE(20%): Like many luekemias and lymphomas, sarcomas are occasionally euploid tumors with a single or limited number of chromosomal changes that ocuur early in tumorigenesis and are specific enough to serve as diagnostic markers. Commonly arise in younger individuals.

COMPLEX KARYOTYPE(80%):These tumors are usually aneuploid or polyploid and demonstrate multiple chromosomal gains and losses, a feature that suggests an underlying abnormality producing genomic abnormality.Such tumors are common in adults.

TOPIC-3

GROSS FEATURES OF SOFT TISSUE TUMOURS

Topic-4

MICROSCOPY OF SOFT TISSUE TUMORS

TOPIC-5

GENETICS OF SOFT TISSUE TUMORS

Sources:-

Robin's and cortan pathology

Harsh Mohan pathology

Internet