Bimonthly assessement

1) A 55 year old man with Recurrent Focal Seizures

Detailed patient case report here: http://ushaindurthi.blogspot.com/2020/11/55-year-old-male-with-complaints-of.html


1. What is the problem representation of this patient and what could be the anatomical site of lesion ?

Ans-Pt (55 year old male )presented with the complaints of unable to move his right upper limb, since yesterday and recurrent episodes of seizures since one day .

Antomical site of lesion is RT temporal lobe ,epileptogenic focus.


2. Why are subcortical internal capsular infarcts more common that cortical infarcts?

subcortical infarcts are caused by occlusion of a penetrating arteries These arteries arise at sharp angles from major vessels so subcortical infarcts are more common that cortical .


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?


ST depressions noted in  leads V1 to V6
NSTEMI

Yes I agree, Enoxaparin is the only LMWH compound to have demonstrated sustained clinical and economic benefits in comparison with UFH in the management of unstable angina/ NSTEMI.


5. Which AED would you prefer? If so why? Please provide studies on efficacies of each of the treatment given to this patient.
 
.ans)carbamazepine and lorazepam / diazepam to prevent the conversion of focal seizure to GTCS


Patient details in the intern logged online case report here: http://manojkumar1008.blogspot.com/2020/12/shortness-of-breath-with-high-sugars.html

Questions:
1. What is the problem representation for this patient? 

55 yr old male who is DM 2  presented with the c/o ,dyspnea on exertion ,cough since 3 Days,sudden onset giddiness and profuse sweating sec to OHA,induced hypoglycaemia.


2. What is the cause for his recurrent hypoglycemia? And how would you evaluate?

Ans) cause for recurrent hypoglycaemia may be over dose of OHA,alcohol .

As  pt is on Glimi, it’s mechanism of action is 

Bind to the sulfonylurea receptor on beta cells ,closes atp channels ,inhibits potassium efflux,and increases insulin secretion .this may be cause for hypoglycaemia.

Alcohol causes increased sugar levels, in the blood leading to increased insulin release may be leading to hypoglycaemia.


3. What is the cause for his Dyspnea? What is the reason for his albumin loss?

Ans)obesity may cause decrease in chest wall compliance ,and respiratory muscle strength leading to dyspnea.

Hypoalbuminemia- may be due to albuminuria secondary to diabetic nephropathy.


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.

Ans) Yes , because her renal parameters are deranged .



1. How would you evaluate further this patient with Polyarthralgia? Polyarthralgia?



2. What is the pathogenesis involved in RA?




3. What are the treatment regimens for a patient with RA and their efficacies?

Ans) treatment for RA ,having symptoms for more than 6 months .




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?
  
Ans) Delayed haemolytic reaction 
          Transfusion related acute lung injury 
           Post transfusion 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?

Ans) Yes I agree .

  • Lasix & Nebulization : For wheezing and crepts
  • Lactulose : To prevent hepatic encephalopathy 
  • Zofer : For vomitings
  • Pantop : To prevent gastritis


1. What is the problem representation of this patient?

60 yr old female ,with DM2 came with the chief complaints of pricking type of chest pain ,burning epigastric pain and constipation since 3 days .


2. What are the factors contributing to her uncontrolled blood sugars?




3. What are the chest xray findings?

Plain radiograph of chest , frontal view

Trachea shifted towards right
Hyperdense area noted in the right upper lobe 
pulmonary vasculature is normal


4. What do you think is the cause for her hypoalbuminaemia? How would you approach it?
 
Ans)
  • Albuminuria
  • Malnutrition

Approach for hypoalbuminaemia.



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 vomiting


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

Ans: Liver : liver failure

Kidney : AKI

GI :  portal hypertension

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



5. What are the efficacies of each treatment given to this patient? Describe the efficacies with supportive RCT evidence. 

  • Tenofovir : for HBV
  • Vitamin -k : for ? Deranged coagulation profile (PT , INR & APTT reports not available)
  • Pantop : for gastritis
  • Zofer : to prevent vomitings
  • Monocef (ceftriaxone) : for AKI (? renal)



1. What is the problem representation of this patient?


A 58 year old weaver occasional alcoholic c/o 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.
Urinary urge incontinence since 6 months.
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 (? Vascular - post stroke sequale)
 

2. How would you evaluate further this  patient with Dementia?
 



3. Do you think his dementia could be explained by chronic infarcts?
 
Ans: yes




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

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 year old delivery boy chronic alcoholic and tobacco chewer c/o on & off fever since 1 year , involuntary weight loss since 6 months , headache since 2 months , 4 - 5 episodes of involuntary stiffening of both UL & LL with 5 min LOC 1 week before the day of admission.

Brain - multiple ring enhancing lesions in right cerebellum ? Tuberculoma
RVD positive


2. What the your differentials to his ring enhancing lesions?

Bacterial
Pyogenic abscess
Tuberculoma and tuberculous abscess Mycobacterium avium-intracellulare infection Syphilis
Listeriosis

Fungal
Nocardiosis
Actinoimycosis 
Rhodococcosis 
Zygomycosis
Histoplasmosis
Coccidioidomycosis
Aspergillosis
Mucormycosis
Paracoccidioidomycosis
Cryptococcosis

Parasitic
Neurocysticercosis
Toxoplasmosis
Amoebic brain abscess
Echinococcosis
Cerebral sparganosis
Chagas\" disease

Neoplastic
Metastases
Primary brain tumor
Primary CNS lymphoma

Inflammatory and demyelinating
Multiple sclerosis
Acute disseminated encephalomyelitis
Sarcoidosis
Neuro-Behcet.s disease
Whipple\"s disease
Systemic lupus erythematosus


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.

Post stroke dementia and its management 
Transfusion reaction
Beclofenac usage in alcohol withdrawal seizures
Hypertensive urgency
Diabetic neuropathy and its diagnosis clinically 
Nstemi and stemi clinical presentation
Alcohol withdrawal seizures pathogenesis and treatment
Hypoglycemia effects on the body
Resistent hypertension treatment 




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