Monthly assessment

Monthly assessment 

d1) 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 

 A 55 year old male construction worker with T2DM who is a chronic alcoholic and smoker came with c/o weakness of right upper limb with involuntary movements of both right UL and LL secondary to ? right 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 .subcortical infarcts are more common than cortical infarcts. 

 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 , Enoxaparin.

https://www.sciencedirect.com/science/article/pii/S0735109702029017

 5. Which AED would you prefer? If so why? Please provide studies on efficacies of each of the treatment given to this patient. 

Yes.carbamazepine

And lorazepam / diazepam to prevent the conversion of focal seizure to GTCS

Antiepileptics https://pubmed.ncbi.nlm.nih.gov/28661008/

Atorvastatin https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6036014/

Aspirin https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6206448/

Enoxaparin https://www.sciencedirect.com/science/article/pii/S0735109702029017

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? 

A 55 year old male with T2DM c/o exertional dyspnea and cough since 3 days and sudden onset giddiness and profuse sweating secondary to OHA induced hypoglycemia

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

Drug induced hypoglycemia 

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

DYSPNEA:

Obesity increases dysnea because of the decrease  in chest wall compliance and respiratory muscle strength.

Pulmonary function abnormalities resulting from obesity

Reduction in lung volumes,increase in pulmonary diffusion

HYPOALBUMINEMIA:

Spot protein creatinine ratio > 1 --- 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.

Yes .starting antibiotics as his renal parameters are deranged 

Spot urine sodium is high may be secondary to ATN

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? Polyarthralgia?

2. What is the pathogenesis involved in RA?

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

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 

-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?

Yes.

• 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 year old female with T2DM c/o pricking type of chest pain since 4 days and uncontrolled sugars secondary to ? right upper lobe pneumonic consolidation with sepsis 

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

Heart is central in position

The diaphragm is normal in position

4. What do you think is the cause for her hypoalbuminaemia? How would you approach it?

• Inflammation 
• Albuminuria
• Malnutrition 

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 : cirrhosis

Kidney : AKI ,Hyperkalemia

GI :  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 contaminatio

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 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?

Yes

4. What is the likely pathogenesis of this patient's dementia?

Post stroke dementia

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 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