MY JOURNEY AS AN INTERNEE IN MEDICINE DEPARTMENT

1)self- reflective writing on their medical student career:

Hello, I am NIHARIKA PENUKONDA, Internee 2k18 BATCH.

 I am here to share my internship journey in medicine department.First of all I would like to express my gratitude to our HOD sir, faculty, and post-graduate sirs and madams who guided me at every step, enabling me to successfully complete my internship despite encountering numerous challenges.

In the begining of my journey in medicine posting i faced some difficulty while handling  clinical duties and communicating  with patients and attending rounds but later with the support of my pgs, faculty i learnt how to balance each and every aspect of medical care that we supposed to deliver to the patient and how to integrate  with other departments. I  got the opportunity to learn and see new cases  while attending rounds.

My actual journey in medicine was commenced when i was in 5th semester. For the first time i was exposed to real patients in icu, wards and the concept of  creating patient blogs and  learnt how to take detailed history and correlate clinical findings and investigations and made me think of various causes of a particular condition and how to  contribute my share as a helping hand in patient care and better outcome.

When i get started my postings my first case was a 40 yr old male who came with complaints of bilateral lower limb swelling since 20days. Generalized anasarca since 15days and Shortness of breath grade 3 and 4 since 10days. I took history and learnt about causes of his pedal edema and shortness of breath ,and pg s helped me in examining and understanding  about the case and mechanism behind  his pedal edema and sob and the patient was diagnosed  with  Pulmonary oedema secondary to acute left ventricle failure, anemia secondary to renal failure with HTN.

Here is the blog link:

https://niharikapenukonda122.blogspot.com/2022/01/a-40-yr-old-male-with-ckd.html

I started my journey as an internee  in medicine department from 1/12/23 to 31/1/24.

1/12/23 - 15/12/23 : psychiatry 

16/12/23 - 31/12/23 : Units

1/1/24 - 15/1/24 : Peripherals 

16/1/24 - 31/1/24 : Units

Psychiatry:

Learning points:

Learnt  detailed history taking and developing rapport with the patient to gain trust and maintaining confidentiality and helping patient to cope up with the condition and counselling and monitoring.

Cases that i saw during my posting in psychiatry:

ALCOHOL DEPENDENCE SYNDROME

TOBACCO DEPENDENCE SYNDROME 

OCD

SCHIZOPHRENIA

DEPRESSION

My offline logs in psychiatry:

During ICU duties , I encountered different cases like some stroke cases and heart failure cases. Saw some cases who came with shortness of breath  and unresponsive states and eventually succumbed into ventilators and most of the cases successfully came out of ventilators ,extubated and unfortunately some couldn't despite of our medical team efforts. Saw a case of dengue fever who came  in dengue shock syndrome and learnt about fluid management and platelet correction in dengue cases.

Learnt how  to monitor patient vitals and hemodynamics, fluid management, cpr etc in icu

During nephrology duties, i got chance to encounter many ckd cases who came for dialysis. Most of  the patients came with shortness of breath and anemia as a complication of ckd and other comorbidities. Learnt how to manage complications that occur during dialysis sessions like high bp, fever spikes with chills, etc .Did numerous  blood transfusions simultaneously with dialysis sessions for anemic ckd patients.

During unit duties ,  learnt how to follow up a case since admission to till discharge. particularly on op days, learnt how to take history of a patient and hod sir guided us how to examine a case and understanding how the disease is affecting patients life ( physically, mentally and socially).

2) Evidence based date wise workflow logs collated as a medical student (From 3rd MBBS to Internship) with clickable and verifiable links

Case 1:

https://niharikapenukonda122.blogspot.com/2024/01/40-yr-female-came-with-co-upper-and.html

Case 2:

https://niharikapenukonda122.blogspot.com/2024/01/a-50-yr-old-female-came-complaints-of.html

Case 3:

https://niharikapenukonda122.blogspot.com/2023/12/this-is-a-online-e-log-book-to-discuss.html

Some of my others blog done during ug:

Case 4:

https://niharikapenukonda122.blogspot.com/2022/10/a-60yr-old-female-came-with-sob.html

Case 5:

https://niharikapenukonda122.blogspot.com/2022/01/a-40-yr-old-male-with-ckd.html

Case 6:

https://niharikapenukonda122.blogspot.com/2023/01/a-24-year-old-male-with-vomiting-sob.html

Case 7:

https://niharikapenukonda122.blogspot.com/2022/10/a-65-yr-old-male-with-chief-complaints.html

Case 8:

https://niharikapenukonda122.blogspot.com/2022/10/a-75-old-female-with-chief-complaints.html

Pajrs:

https://chat.whatsapp.com/ITRPEf7cMvU5FKyq5WtQaF

https://chat.whatsapp.com/HSYRc1orX2CDhwIx3Yuayg

Bed side osce:

https://youtu.be/ddenMymfULQ?feature=shared

I was given an opportunity to participate in "Real patient Osce's" blooming by the bedside conducted as a part of general medicine cpd on 25/1/24. It was a very enlightening session done bedside in icu of our hospital. I would like to thank Dr. Rakesh Biswas sir for arranging this session.

https://youtu.be/ezJ8CA6Y1ks?si=t9usSuTw1lPTSesI

Learning points and discussion topics covered in osce:

1)How to differentiate diabetic kidney disease from non diabetic kidney disease.

2) obstructive sleep apnea.

3) hyponatremia correction and complications with rapid correction.

My offline logs( daily work flow):

 

3) Anecdotal self reflections on their internship learning with some video evidence of procedures performed:

During icu and nephro postings, learnt about:

1.Foleys catheterization for urine output

2. Drawing ABG samples and interpreting it

3.Ryles tube insertion

4. 2d echo

5. Learnt about Dialysis and monitoring vitals during dialysis and how to manage hemodynamics  of patient and complications during dialysis.

 RYLES TUBE INSERTION FOR FEEDING:

 

6. Assisted central line  and done suturing for it during nephrology duties:

7. Learnt about renal biopsy, how to perform biopsy and what are the complications associated with it .

Thanks for Dr. Krishna chaitanya sir, Dr.Bharath kumar sir nd Dr. Harika mam for sharing knowledge and giving me opportunity to learn about renal biopsy

8.  Did Ascitic tap

9.Done CPR

Osce:

1) Obstructive sleep apnea diagnostic criteria:

Obstructive sleep apnea (OSA) is characterized by episodes of breathing cessation or shallow breathing in sleep. These episodes are due to complete or partial collapse of upper airway. Most of the time, the respiratory events are associated with snoring, oxygen desaturations and brief arousal from sleep.

Sleep apnea is usually worse during supine and Rapid Eye Movement (REM) sleep. There could be exacerbation of snoring and OSA with alcohol consumption or ingestion of sedative medications.

Diagnostic criteria:

Modified from International Classification of Sleep Disorders – Third edition (ICSD-3)5 (A and B) or C satisfies the criteria:

A. The presence of one or more of the following

The patient complains of sleepiness, nonrestorative sleep, fatigue, or insomnia.

The patient wakes with breath holding, gasping, or choking.

The bed partner or an observer reports habitual snoring or breathing interruptions in sleep.

The patient has hypertension, a mood disorder, cognitive dysfunction, coronary artery disease, stroke, congestive heart failure, atrial fibrillation, or type 2 diabetes mellitus.

B. Polysomnography (PSG) or out-of-center sleep testing (OCST) demonstrates

Five or more predominantly obstructive respiratory events (obstructive apneas, hypopneas, or respiratory effort related arousals [RERAs]) per hour of sleep during a PSG or per hour of monitoring (OCST).

C. PSG or OCST demonstrates

Fifteen or more predominantly obstructive respiratory events (apneas, hypopneas, or RERAs) per hour of sleep during a PSG or per hour of monitoring (OCST).

Definition or Scoring of Respiratory Events During PSG:

In adults, various respiratory events are defined and scored per the criteria laid out by the AASM Manual for the Scoring of Sleep and Associated Events.

An obstructive apnea is scored if there is a drop in the respiratory effort signal by ≥90% of pre-event baseline, for ≥10 seconds and continued or increased inspiratory effort from chest and/or abdomen.

A hypopnea is defined when there is drop in the respiratory effort by ≥30% of pre-event baseline for ≥10 seconds, associated with oxygen desaturation by ≥3% (AASM criteria) or by ≥4% (CMS criteria).

A Respiratory Effort-Related Arousal (RERA) is scored if there is flattening of the inspiratory nasal pressure for ≥10 seconds causing an arousal from sleep, but not meeting criteria for an apnea or hypopnea.

The severity of OSA is determined by an index – Apnea Hypopnea Index (AHI) or Respiratory Disturbance Index (RDI), if PSG is preformed, or Respiratory Event Index (REI) if OCST is performed.

AHI = number of Apneas+Hypopneas/total sleep time

RDI = number of Apneas+Hypopneas +RERAs/total sleep time

REI = number of Apneas+Hypopneas/monitoring time

AHI or REI <5/hour = normal (for adults); 5–14.9/hour = mild OSA; 15–29.9/hour = moderate OSA; and ≥30/hour = severe OSA.

Screening tools:

Stop bang questionnaire 

S	Do you Snore loudly?
T	Do you feel Tired or sleepy during the day?
O	Has anyone Observed apneas or choking during sleep?
P	Do you have high Blood Pressure
B	BMI > 35
A	Age > 50
N	Neck circumference ≥17 inches (men); ≥16 inches (women)
G	Gender - male

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6140019/

2) How to differentiate b/w chyluria and pyuria:

Chyluria, which is passage of chyle in urine that gives its milky appearance, has many causes, which are parasitic and non parasitic. The lymph laden with fat that has been absorbed from intestine is responsible for the milky appearance. Large amount of chyle in urine or other fluid like, ascitic or pleural fluid can be easily identified on naked eye examination. However, detection of smaller amounts requires special tests.

Milky or hazy appearance of urine also may be due to presence of high phosphate or huge pus cells. Phosphaturia, which settles on standing the urine at room temperature, can be excluded by adding few drops of 5% acetic acid. Pyuria can be confirmed by centrifuging the sample that gives a clear upper and a hazy lower zone of the fluid and then by microscopy.

There are several methods of detection of chyle in urine. Use of fat solvent (ether) almost completely clear the opacity. Chylomicrons can be directly visualized under microscope with dark ground illumination or stained with Sudan III.

Recently triglyceride has been demonstrated to be universally present in chyluria, even in clear urine. The amount of triglyceride has been found to be directly proportional to the haziness of the chylous urine.

When present in concentrations of 100 mg/dl or less, triglyceride does not give a hazy appearance to the naked eye. Measurement of can be done by biochemical analyzer or a photoelectric colorimeter using the standard methods of measurement of triglyceride as in serum.

Method: After adding a few drops of 5% acetic acid to 1 ml of chylous urine, urine was centrifuged for 3 minutes at 3000 rpm. If it clears, it indicates phosphate or pus, which can be confirmed by examining the deposit under microscopy. If the supernatant is still opaque (chyle), then urine from upper part of the test tube is used for the measurement of triglyceride.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3391817/