Bimonthly Assignment
) A 55 year old man with Recurrent Focal Seizures
1. What is the problem representation of this patient and what could be the anatomical site of lesion ?
A 55 year old male came with
A--1)Involuntary movements of right upper and lower limbs.
2)Right upper limb weakness
3)DM II
4)Chronic alcoholic and chronic smoker since 35 years.
O/E :Clubbing +, bilateral Inspiratory crepts in all areas.
B-- right temporal lobe epileptogenic focus.
2. Why are subcortical internal capsular infarcts more common that cortical infarcts?
subcortical infarcts are more common than cortical infarcts because the penetrating arteries which supply them have small diameter and arise from major arteries of greater volume at a certain angle that makes them more prone for occlusion and rupture.Thus making sub cortical infarcts more common.
3. What is the pathogenesis involved in cerebral infarct related seizures?
4. What is your take on the ecg? And do you agree with the treating team on starting the patient on Enoxaparin?
Left axis deviation is seen
ST depressions noted in precordial leads V1 to V6
NSTEMI
5. Which AED would you prefer?
If so why?
Please provide studies on efficacies of each of the treatment given to this patient.
I would prefer carbamazepine.
Questions:
1. What is the problem representation for this patient?
A 55 year old male with
1) Hypoglycemia : giddiness and profuse sweating with GRBS -34mg/dl
2) Shortness of breath (grade 2-3) since 3 days
3) Dry Cough since 3 days
4)K/C/O DM II and HTN since 10 years.
2. What is the cause for his recurrent hypoglycemia? And how would you evaluate?
Drug induced Hypoglycemia as patient is on OHA.
Elevated Serum Creatinine and Significant loss of proteins in his urine indicates Renal Failure.
3. What is the cause for his Dyspnea? What is the reason for his albumin loss?
Patient being morbidly obese might have lead to dyspnea because of decreased cheat wall complaiance.
Due to diabetic nephropathy,where there is albuminuria might have lead to Hypoalbuminemia.
4. What is the pathogenesis involved in hypoglycemia ?
5. Do you agree with the treating team on starting the patient on antibiotics? And why? Mention the efficacies for the treatment given.
No,I don't agree starting the patient on antibiotics as there is no clinical feature supporting infection.
3(A)
41 year old man with Polyarthralgia
Case details here: https://mahathireddybandari.blogspot.com/2020/11/41m-with-chest-pain-and-joint-pains.html?m=1
1. How would you evaluate further this patient with Polyarthralgia?
2. What is the pathogenesis involved in RA?
3. What are the treatment regimens for a patient with RA and their efficacies?
csDMARD: conventional synthetic disease-modifying antirheumatic drugs - methotrexate, leflunomide, sulfasalazine, and antimalarial drugs (hydroxychloroquine and chloroquine).
tsDMARD: synthetic target-specific disease-modifying antirheumatic drug - tofacitinib.
bDMARD: biological disease-modifying antirheumatic drugs - tumor necrosis factor inhibitors/TNFi (adalimumab, certolizumab, etanercept, golimumab, infliximab), T-lymphocyte co-stimulation modulator (abatacept), anti-CD20 (rituximab), and IL-6 receptor blocker (tocilizumab).
boDMARD: original biological disease-modifying antirheumatic drugs.
bsDMARD: biosimilar biological disease-modifying antirheumatic drugs.
3(B)
75 year old woman with post operative hepatitis following blood transfusion
Case details here: https://bandaru17jyothsna.blogspot.com/2020/11/this-is-online-e-log-book-to-discuss.html
1.What are your differentials for this patient and how would you evaluate?
-Post transfusion delayed hemolytic reaction.
Evaluation-
ABO and Rh compatability
coombs testing
antibody panel testing
https://www.learnhaem.com/courses/frcpath-transfusion/lessons/antibody-screening-and-identification/topic/antigrams/
-Transfusion related acute hepatic injury (TRAHI)
-Post transfusion hepatitis
-Ischemic hepatitis
Evaluation:
2. What would be your treatment approach? Do you agree with the treatment provided by the treating team and why? What are their efficacies?
Symptomatic management
I agree with the treatment provided by the treating team
Lasix & Nebulization : For wheezing and crepts
Lactulose : To prevent hepatic encephalopathy https://pubmed.ncbi.nlm.nih.gov/27089005/
Zofer : For vomitings
Pantop : To prevent gastritis
4) 60 year woman with Uncontrolled sugars
http://manojkumar1008.blogspot.com/2020/12/60-yr-old-female-with-uncontrolled.html
1. What is the problem representation of this patient?
A 60/F house wife by occupation with
1) burning type epigastric pain since 3 days
2) constipation since 3 days
3)K/C/O HTN and DM II since 2 years
4)H/O 1 episode of seizure 1 year back.
2. What are the factors contributing to her uncontrolled blood sugars?
Patient is not taking her OHA regularly and also as there is sepsis-
3. What are the chest xray findings
Trachea shifted towards right.
1-consolidation in right upper lobe
2-Peripheral pulmonary vasculature is normal
3-Heart is central in position
4-Cardiac size normal
5-The domes of diaphragm are normal in position and smooth outline
4. What do you think is the cause for her hypoalbuminaemia? How would you approach it?
Inflammation (acute phase reactant)
Malnutrition
Albuminuria (protein losing nephropathy)
Approach to hypoalbuminemia:
5. Comment on the treatment given along with each of their efficacies with supportive evidence.
Piptaz & clarithromycin : for his right upper lobe pneumonic consolidation and sepsis
Egg white & protien powder : for hypoalbuminemia
Lactulose : for constipation
Actrapid / Mixtard : for hyperglycemia
Tramadol : for pain management
Pantop : to prevent gastritis
Zofer : to prevent vomitings
5) 56 year old man with Decompensated liver disease
Case report here: https://appalaaishwaryareddy.blogspot.com/2020/11/56year-old-male-with-decompensated.html
1. What is the anatomical and pathological localization of the problem?
Liver : Chronic liver disease (cirrhosis) secondary to HBV
Kidney : AKI on CKD (Hepatorenal syndrome) , Hyperkalemia
GI : GAVE , portal hypertensive gastropathy
Lung : pneumonia , pleural effusion
2. How do you approach and evaluate this patient with Hepatitis B?
3. What is the pathogenesis of the illness due to Hepatitis B?
4. Is it necessary to have a separate haemodialysis set up for hepatits B patients and why?
Yes , separate machines must be used for patients known to be infected with HBV (or at high risk of new HBV infection). A machine that has been used for patients infected with HBV can be used again for non-infected patients only after it has been decontaminated using a regime deemed effective against HBV because of increased risk of transmission due to contamination.
https://bmcnephrol.biomedcentral.com/articles/10.1186/s12882-019-1529-1
5. What are the efficacies of each treatment given to this patient? Describe the efficacies with supportive RCT evidence.
Lactulose : for prevention and treatment of hepatic encephalopathy. https://pubmed.ncbi.nlm.nih.gov/27089005/
Tenofovir : for HBV
Octreotide : for upper GI bleed. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1750992/#:~:text=In%20a%20meta-analysis%2C%20somatostatin,(mostly%20caused%20by%20gastritis).
Lasix : for fluid overload (AKI on CKD) https://www.ncbi.nlm.nih.gov/books/NBK499921/#:~:text=The%20Food%20and%20Drug%20Administration,failure%20including%20the%20nephrotic%20syndrome.
Vitamin -k : for ? Deranged coagulation profile (PT , INR & APTT reports not available)
Pantop : for gastritis
Zofer : to prevent vomitings
Monocef (ceftriaxone) : for AKI (? renal)
6) 58 year old man with Dementia
Case report details: http://jabeenahmed300.blogspot.com/2020/12/this-is-online-e-log-book-to-discuss.html
1. What is the problem representation of this patient?
A 58/M weaver by occupation with
1) slurring of speech , deviation of mouth to right side associated with drooling of saliva , food particles and water predominantly from left angle of mouth and smacking of lips since 6 months.
2)He has delayed response to commands.
Dysphagia to both solids and liquids since 10 days.
3)Urinary urge incontinence since 6 months.
4)Forgetfulness since 3 months.
He has delayed response to commands.
Dysphagia to both solids and liquids since 10 days.
K/c/o CVA 3 years back and now he was diagnosed as neuro degenerative disease - Alzheimer's.
2. How would you evaluate further this patient with Dementia?
3. Do you think his dementia could be explained by chronic infarcts?
Yes
4. What is the likely pathogenesis of this patient's dementia?
Post stroke dementia
post-stroke dementia may be the direct consequence of vascular lesions in the brain
- post-stroke dementia could be the result of pre-existing neuropathological effects AD's related
- recurrent stroke that is cause by vessel damages and by white matter lesions that may lead to cognitive decline and contribute to post-stroke dementia;
One of the mechanism involved in ischemic VaD is under the control of large vessels disease (atherosclerosis, and other arteriopathies), however, impaired cerebral flow in the absence of infarct as consequence of arterial stenosis has been documented, although its clinical consequences remain to be fully investigated. It is also unclear whether and to what degree large vessel disease contributes to the white matter pathology and lacunes associated with the subcortical type of VaD. Statistical association suggests it may have additive effects to small vessel pathology.
5. Are you aware of pharmacological and non pharmacological interventions to treat such a patient and what are their known efficacies based on RCT evidence?
PHARMACOLOGIC:
Cholinesterase inhibitors:
Donepezil
Rivastigmine
Galantamine
NMDA antagonist:
Memantine
NON PHARMACOLOGIC:
Counselling the patient and care givers
Geriatric care
Cognitive / emotion oriented interventions
Sensory stimulation interventions
Behaviour management techniques
Efficacy:
https://pubmed.ncbi.nlm.nih.gov/9443470/
7) 22 year old man with seizures
Case report here http://geethagugloth.blogspot.com/2020/12/a-22-year-old-with-seizures.html
1. What is the problem representation of this patient ? What is the anatomic and pathologic localization in view of the clinical and radiological findings?
A 22 /M delivery boy by occupation with
1) involuntary stiffness of both upper and lower limbs
2) Headache
3) involuntary weight loss in past 6 months
4) Chronic alcoholic and tobacco chewer
Brain - multiple ring enhancing lesions in right cerebellum ? Tuberculoma
RVD positive
2. What the your differentials to his ring enhancing lesions?
3. What is "immune reconstitution inflammatory syndrome IRIS and how was this patient's treatment modified to avoid the possibility of his developing it?
A paradoxical clinical worsening of a known condition or the appearance of a new condition after initiating anti retroviral therapy (ART) therapy in HIV-infected patients resulting from restored immunity to specific infectious or non-infectious antigens is defined as immune reconstitution inflammatory syndrome (IRIS).
As his CD4 count is > 50 /mm3 consider delayed initiation of ART ideally after 8 weeks of starting ATT to reduce the chances of developing IRIS
8) Please mention your individual learning experiences from this month.
- Antihypertensives and antidiabetic drugs commonly used in clinical settings and their dosages.
-Transfusion reactions.
-counselling a RVD+ patient.
-ECG Interpretation.
-LFT Interpretation
-Managing uncontrolled sugars conditioned patient
-have seen IgG related disease case.
-How to interpret an ABG.
