DAILY eLOGS

                     I feel very fortunate for practicing the branch of my

 choice where I get to see vast variety of  cases  on day to day basis.

 Here I will be sharing few of my experiences during my junior

 residency .  I have seen closely majority of cases during my first

 year of residency.

                   One of the mind blowing case was of Non Hodgkins 

Lymphoma, the patient presented with fever of high grade with

 anorexia, he was almost worked up for 2 weeeks but we couldnt find

 any conclusive diagnosis. we ultimately labelled him as pyexia of

 unknown origin. Then gradually after weeks of stay in

 hospital patient started developing vague abdominal pain which 

made us repeat his usg abdomen and Erect X ray abdomen which 

showed mediastinal lymphadenopathy. we tried palpating the rest 

group of lymph nodes for any enlargement but there was only 

mediastinal lymphadenopathy, as we couldnt get any  cause for his 

lymph node enlargement , we planned for a lymph node biopsy ct 

guided , which showed features suggestive of non hodgkins 

lymphoma , further tumour marker study was done and patient

 was immediately started on chemotherapy, currently patient is 

recieving chemotherapy at government hospital. His entire workup 

took almost 3 months. Accurate clinical examination is a key to 

diagnosis. I got to perform ct guided biopsy of medistinal lymph 

node which is a rare thing generally done at hospitals. It was done 

with the help of radiologist.

                  Another case was an interesting case of refracatory 

ascitis, he was an elderly male alcoholic who presented with 

massive abdominal distention , the detailed history and the entire 

workup was done ,It was an exudative type of ascitis with greenish 

discolouration on ascitic fluid analysis,but we werent able  to 

localise the cause, initially though of bowel perforation, appropriate 

workup was done , erect abdomen x ray dint show any gas under 

diaphragm, even tried giving contrast orally to look for any bowel 

perforation but nothing could be found out, after taking consultation 

with the surgeons planned for a laparotomy after getting an imaging 

done, CECT dint show up relevant but radiologist wanted to repeat 

the USG abdomen , fortunately there was a hidden  perforation of 

the gall bladder, with cholecystitis, the patient was operated , 

cholecystectomy was done and he was sent home happily.so here it 

was a team approach where physicians , radiologist and surgeons 

collaborated and were able to clinch the diagnosis. This case was 

one of the priceless experience I had during my residency.

                     I had an oppurtunity of placing central lines to the 

dialysis patients. The technique of placing a central line is 

something which we learn out of experience , around 15 to 20 

central lines I was able to perform during my Nephrology postings.

                     During my critical care postings I had the maximum 

oppurtunity of attaining procedural skills like managing an almost 

dead patient  by intubting patient, if necessary performing a CPR on 

the patient. I had an oppurtunity of doing lumbar puncture in cases 

of meningitis and gullian barre syndrome.

                     Under the guidance of my professors I was able to do 

postmortem biopsy of lung , liver and kidney which is a rare 

experience one can get.

                     I would like to share another interesting case where 

possibly nothing much could have been done to  the patient , I found 

myself so helpless in this situation. It was  a case of an elderly man 

who came all the way from nepal to get treated under my professor, 

he presented with abdominal distention with tense ascitis, he was a 

chronic alcoholic and was clinically diagnosed with decompensated 

cirrhosis, he was put on conservative management like therapeutic 

paracentesis, he was there with us for almost 1 month, tolerating the 

conservative management , we wanted to rule out infective etilogy 

hence was screened for hepatvirus serology and it turned out to be 

Hepatitis C positive, we wanted to start the antivirals but  the patient 

was not affordable for the treatment , even we residents and the 

management couldnt do much , one fine evening he started having 

bouts of blood stained vomiting, as ours is a tertiary care centre we 

dint had availability of a gastroenterology , we tried giving cold 

saline, betablockers, as much as we can, but the patient breathed his 

last. At times standard of care decides the outcome of the patient.

                  I had an oppurtunity of presenting many seminars and 

case presentations in the department and mortality meets and 

debates, which was a very good experience, it helped me in 

justifying my diagnosis.