"MY EXPERIENCES WITH GENERAL CELLULAR AND NEURAL CELLULAR PATHOLOGY IN A CASE BASED BLENDED LEARNING ECOSYSTEM’S CBBLE”
Hello everyone,
I am Saptarshi Saha, a 4th year medical student studying MBBS Jinan University in China. As a medical student, my journey has been full of ups and downs, excitement and surprises, but one of the most impactful and thrilling experience for me has been writing, preparing and presenting medical case reports (like painting the real life portrait of an individual).
Each individual is unique and every“body” has something new to tell. Preparing case reports is what I believe to be the best way to deal with medical issues and gain deep insights into healthcare problems. So, in this blog I invite you to be my companion in this journey to explore few of the many interesting cases from my portfolio, which I got the opportunity to prepare till date under the guidance of my esteemed professor Dr. Rakesh Sir (HOD medicine KIMS) and my Seniors whose valuable inputs have made my learning experience much more impactful.
I welcome all the readers to explore these case reports with me as a method of learning and to contribute to the growing database of medical knowledge. Patients and their particular circumstances are unique, and these case reports are useful in helping healthcare providers tailor their assessment and treatment to accommodate such individual needs.
At the end I would like to say that most of the case reports were done through telephonic conversation from 2000 miles away. Still, I had tried my level best to paint these live portraits as carefully in a detailed manner as possible.
So, without further ado let’s get started.
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Feb 11 2022, no it’s not my birthday. It’s the day when this journey began. I was sitting in my room, leafing through the pages of Netter’s atlas when at around 6:45 pm my senior called me saying “Saptarshi, can you help us prepare the case report of this man who hails from your state and speaks your mother tongue?”. Without giving it a second thought I said “yes please”. Though the case was not a very complicated one, I had an invaluable experience and learnt a lot because it was my first case report filing.
Let’s have a look…..
He was a male patient, aged 33 years. Seeing me speak his mother tongue he was quite delighted and eagerly shared all his details which helped a novice like me file a detailed case history which was quite fundamental for arriving at a final diagnosis within a short period of time.
The first thing that caught my attention was the mild swelling of his left cheek. He complained of pus oozing out from the upper left posterior teeth region especially while sneezing or lying down for the past 1 and a half month accompanied with pain and swelling.
On examination of oral cavity pus point seen posterior to 3rd molar in the left upp. gingival area. Active pus discharge seen on pressing upper gingival sulcus, region distal to 27. On palpation, bulging and tenderness present in left gingivobuccal sulcus lateral to canine.
Further radiological investigation suggestive of left maxillary sinusitis with osteomyelitis changes in the left floor and medial and lateral borders of the maxillary sinus. Pro antral communication distal to #28 region.
Enterococcus and fusobacterium species grown in pus culture.
CECT neck revealed an expansive unilocular lytic lesion involving the maxillary arch on the left side building in the lumen of the left maxillary sinus. The lesion was causing significant narrowing of the maxillary sinus and reaching up to orbital floor superiorly. Significant cortical thickening was noted with multiple areas of cortical break involving the posterior and anterior superior aspect.
A provisional diagnosis of Left oroantral fistula with chronic maxillary sinusitis, left spheroid degeneration with Denovo DM type II was made.
Histopathological features of the biopsy sample suggestive of inflammatory lesions.
Surgery executed: Enucleation and curettage of the cyst
Postoperative diagnosis of odontogenic cyst was made.
The detailed case report can be found in the link given below
https://ssahamedicalcases.blogspot.com/2022/02/33-yr-old-male-with-co-pus-oozing-out.html
At that time though I only had some vague idea about odontogenic cysts, I knew nothing about it’s treatment and management plan nor about the above mentioned surgical procedure. To have a first hand experience about knowing the treatment flow of a patient from the time he comes to the hospital till getting discharged and even afterwards, was a valuable learning experience for me.
This was the article that helped me at that time to learn more about odontogenic cyst.
Now, moving on to case 2. This one has an interesting story.....I was walking down the corridor with my friends when I saw a group of young Doctors standing around a bed. And Sir, was explaining something to them...Seeing he Sir said, "Saptarshi, have a look...this is one interesting case, you must try to write a report on him"... The first thing which caught my attention was that even though he was lying down in supine position without any pillow under his head his head, his head appeared to be floating mid-air and his legs were fixed in a flexed position. Sir, explained that he can neither lower his head nor extend his legs rendering him incapable of walking. For the past 7 years he has been confined to bed or chair.
Later, a detailed history taking revealed a lot of interesting facts.
This is the life story of a 65 years old man who was a toddy climber by profession until various health ailments crippled him. In the year 2002, surgery for rt. renal calculi was done. In 2007, ORIF was done for rt. femur #. In 2012, tibia # but no treatment done. In 2013, hip # no treatment sought because of poor financial conditions. Unable to walk since then. He used to do as limited movement as possible otherwise his pain would flare up. In 2015, diagnosed with fixed flexion deformity grade 3 of both knees with bilateral knee pain.
On 2022, he came to us with complaints of anuria, urinary urgency and incomplete voiding of urine. Also complained of SOB grade 2 and there were signs of pedal edema.
NCCT-KUB detected bilateral ureteric calculi causing moderate hydroureteronephrosis, prostatomegaly, left renal calculi 4 mm size.
Xray of the neck and knee joints revealed cervical ankylosis and fixed flexion deformity of knee joints.
After medications and 2 sessions of hemodialysis, his urine output increased. A diagnosis of postrenal AKI secondary to B/L ureteric calculi was made. Patient was recommended to undergo surgery but concent was not given. Hence pateint was discharged.
Though the patient left us...he left us with a lot of questions which remained unanswered.
As we can see this patient is suffering from recurrent renal stones, multiple fractures (indicating weak and brittle bones) from time to time, so I tried to find out if there is any correlation between his ailments and whether fluorosis is the cause of all this problems.
In the below attached link I have done my level best to gather and compiled together all the available information to arrive at a final conclusion. Please have a look....
https://ssahamedicalcases.blogspot.com/2022/02/fluorosis-and-renal-stones.html
Moving on to the final case…
NOTE: this case history was taken via a telephonic conversation which denied me the opportunity to do first-hand physical examination on this patient.
This is the story of a 49 yr old man...
In 2000, one day while watching TV in the club room, he felt the back of his neck and head getting stiff along with the involuntary movement of his head in a "no-no" fashion (at first only visible on careful observation). It lasted for 5-10 secs and happened 1-2 times in a day, a few times a wk, accompanied by a prickling pin and needle sensation along his spine sometimes.
Within few years (2005) the frequency, duration (10-15 mins), and severity increased progressively. A local physician prescribed medication but no relief.
Once while in a market with his employee, he c/o these same symptoms, unable to carry on with the intended work, he sat down. Since that incident, he unwillingly had to pass on more responsibilities to the employees.
Went to Bangalore in 2006, Dr. prescribed Tryptomer 0.25 mg and Lonazep 0.5 mg o.d, taking those provided complete relief for 3 months. Then again it started increasing.
He tried homeopathic treatment, which provided no relief.
Went to Bangalore again in 2008, Dr told him to increase the dosage if req. Doing so provided some relief.
Then he lost contact with his treating Dr and since medicines were becoming less and less effective day by day, he stopped taking those. In the meantime, his symptoms kept on becoming more severe.
He c/o not being able to have proper sleep because whenever, he would lie down in a supine position his involuntary head movement would reappear, so much so that he had to lie down on his sides with a pillow below his head and they went to sleep. In most cases, he failed to get any sleep. Medications by Drs for not being able to sleep did little help.
By 2012, he was not able to maintain balance and was past pointing test +ve (if asked to touch his nose he will touch his eyes instead). He went to Bhopal, Dr did MRI, and diagnosed it to be Spino cerebellar degeneration. Dr. prescribed Liofen 5mg and Clonafit 0.5 MD. But, for a few months, his symptoms reduced a bit, then again like before.
In 2012, he did Ayurveda treatment as his speech was getting slurry. He chewed the roots of the plant "long pepper" till 2016, which he claims to have improved his speech. Before which it was incomprehensible.
By 2013, he was unable to walk without someone's help or support.
By 2015-16, he can't even go downstairs to sit in his shop below his house. In the meantime, he was recurring huge losses in his business, since he had handed the responsibility to the employees.
Till July 2016, he took medications, then gave up since taking those made no difference.
He became confined to his room mostly, sometimes would rarely visit his friend's home nearby (booking an auto from the front gate to reach his friend's house).
In 2018, when his family separated, his BP became very high. Dr diagnosed HTN and since then taking Telvas AM o.d.
For the past 3 yrs, c/o constipation (no defecation for a day or so, hence uses laxatives sometimes ). No digestive issues.
At present, pt is not able to write properly, head movement would happen more when he is doing puja (meditation), watching phone, urinating or defecating, or if stressed out or thinking deeply. But, if he tries to sleep, his head movement stops.
Pt had now attached metal rods all around and inside his house, which he uses to walk around. He reported doing exercise does provide some relief.
Also there is an interesting psychosocial component to it, which can be found in the link given below.
https://ssahamedicalcases.blogspot.com/2023/02/patient-history-pt-is-49-yrs-old-male.html
Since the time he was diagnosed with autosomal dominant cerebellar ataxia, his last and only wish is the discovery of a magic pill that can treat his condition and make him return to normal life.
So, the question which pegged me is how do we manage this kind of patients?
My search for an answer lead me to this article.
As we all know till date hereditary ataxia has no effective treatment and management remains supportive and symptomatic.
In our case how did we manage the patient....well, to support our patient though he is far away from us we created an individualized PaJR group (like we had done for many of our patients)...it helps us keep a track of our patients who need a long term health support.
Everyday this man describes his day's events helping us gauze his condition. He does household chores and physical exercise which even though is not going to cure him....is slowing down his disease progression which is evident from his daily life activities.
Now, it is our responsibility as medical students and researchers to find out that magic pill this patient and many others like him are eagerly waiting for to help them return back to the normal life they want.
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Last few words.....before I end.
From my experience I can say medical case reports provide an opportunity to learn from real-life situations and can increase awareness among healthcare providers concerning particular conditions. It also supplements the associate with scientific advancements by analyzing the results of treatments and the effects of drugs on clinical cases.
To see a patient come to us suffering and leave with a smile on their face is an indescribable feeling. Knowing that I have had even a small part to play in relieving their pain and discomfort brings me so much joy.
Being able to help people and make a difference in their lives is what makes this profession so special. Nothing can bring more happiness than the knowledge that you have helped someone end their suffering........
With this I end here for now....Thank you if you had stayed with me until the end.
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