General medicine assignment May 2021

 Online blended monthly assignment toward summative assessment for the month of May 2021

Name: V.Sai Jaya Krishna

Roll no: 137

Batch: 2017

Semester: 8TH SEMESTER

I have been given the following cases to solve in an attempt to understand the topic of 'Patient clinical data analysis' to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and diagnosis and come up with a treatment plan.

This is the link of the questions asked regarding the cases:http://medicinedepartment.blogspot.com/2021/05/online-blended-bimonthly-assignment.html?m=1

Below are my answers to the Medicine Assignment based on my comprehension of the cases.

Pulmonology

A.Link:

https://soumyanadella128eloggm.blogspot.com/2021/05/a-55-year-old-female-with-shortness-of.html

1Q) what is the evolution of the symptomatology in this patient interms of an event timeline and where is the anatomical localisation for the problem and what is the primary etiology of the patient  problem ?

1Ans)Evolution of symptomatology

20 yr back -1st episode of sob

12 yr back-2nd episode of sob

After that she has been having yearly episodes for the past 12 yrs 

Diagnosed with diabetis - 8yrs back

Anemia and  took iron injections  - 5yr ago

Generalised weakness  - 1 month back 

Diagnosed with hypertension  - 20 days back

Pedal edema - 15 days back

Facial puffiness- 15 yrs back

Anatomical location of problem - lungs

Primary etiology of patient- usage  of chulha since 20 yrs might be due to chronic usage 

2Q)what r the mechanism of action indication and efficacy over placebo of each of the phramacological and nonphramacological interventions  used for this patient?

2Ans)~Head end elevation :# MOA;

.improves oxygenation 

.decreases incidence VAP

.increases hemodynamic performance 

.increases end expiratory lung volume

.decreases incidence of aspiration 

#Indication: .head injury

.meningitis 

.pneumonia 

~ oxygen inhalation to maintain spo2

~Bipap:non invasive method

#MOA :assist ventilation  by delivering positive expiratory and inspiratory pressure with out need for ET incubation9

3. Cause for current acute excerbation - it could be due any infection

4.could the ATT affected her symptoms if so how?

Yes ATT affected her symptoms

Isoniazid and rifampcin -nephrotoxic - raised RFT was seen

Cardiology

Link A:

https://muskaangoyal.blogspot.com/2021/05/a-78year-old-male-with-shortness-of.html

1.What is the difference btw heart failure with preserved ejection fraction and with reduced ejection fraction?

ANS:

-Amount of blood pumped out of the heart with each beat is called the ejection fraction (EF). A normal EF is usually around 55 to 70 percent, but it can be lessened in some forms of heart failure.

-People with heart failure with reduced ejection fraction (HFrEF) have an EF that is 40 to 50 percent or lower. This is also called systolic heart failure. People with heart failure with preserved ejection fraction (HFpEF) do not have much of a change in their ejection fraction. This is often called diastolic heart failure.

 -HFrEF were often diagnosed earlier in life and right after a heart attack. 

 HFpEF were diagnosed later in life and first experienced symptoms of heart failure between the ages of 65 and 69. Many of those with HFpEF also shared that they have other health problems that led to their diagnosis. Many of them also live with additional health conditions, including acid reflux (GERD), high blood pressure, kidney disease, and sleep disorders.

-HFrEF shared that they feel depressed and/or anxious about their heart failure diagnosis. Risk factors for those in this group include genetics or a family history of heart failure.

HFpEF shared that they are still able to do the things they enjoyed before their heart failure diagnosis.risk factors, including:

Sedentary lifestyle

High blood pressure

Sleep apnea

Other heart conditions

-HFrEF are more likely to have had surgery, including surgery to implant a pacemaker or other heart rhythm control device.HFrEF shared that they currently use a combination therapy to treat their heart failure.

HFpEF have never had surgery to treat their heart failure or had a device implanted.

 -HFrEF are men who live in rural areas.

 However, most respondents with HFpEF are women who live in urban areas.

2.Why haven't we done pericardiocenetis in this pateint?        

ANS;

Pericardiocentesis is usually done when the pericardial effusion is not resolving on its own . Here the pericardial fluid which has accumulated was resolving on itw own , at the time of admission it was 2.4mm and when discharged it was 1.9 mm . Therefore we did not do pericardiocentesis in this pt.             

3.What are the risk factors for development of heart failure in the patient?

ANS:   IN THIS PATIENT:

NON MODIFICABLE RISK FACTORS:

age

gender

MODIFIABLE:

hypertension

smoking

type 2 diabetes .

kidney disease.

4.What could be the cause for hypotension in this patient?

ANS:

 

The patient was anemic with Hb of 8gm/dl . One of the severe complication of anemia is tissue hypoxia which further lead to hypotension.

Link B:

https://muskaangoyal.blogspot.com/2021/05/a-73-year-old-male-patient-with-pedal.html

1.What are the possible causes for heart failure in this patient?

ANS:Causes of heart failure:

obesity 

alcohol

diabetes

hypertension

2.what is the reason for anemia in this case?

ANS:  

Alcoholics frequently have defective red blood cells that are destroyed prematurely, possibly resulting in anemia. Alcohol also interferes with the production and function of white blood cells, especially those that defend the body against invading bacteria. Consequently, alcoholics frequently suffer from bacterial infections.

3.What is the reason for blebs and non healing ulcer in the legs of this patient?

ANS:

The pt. had recurrent blebs and ulcer on lower limbs (foot). This is due to Type to diabetes mellitus.

Diabetic foot ulcers generally arise as a result of poor circulation in the foot region. While high blood sugar levels and nerve damage or even wounds in the feet may result in foot ulcers in many cases. 

In cases of poor circulation of blood, the foot ulcers take quite a bit of time to heal as the blood efficiency in the foot region is at a low level. Furthermore, many develop a bit of reduced sensation on the feet as a result of nerve damage or more.

There are many risk factors that may lead to foot ulcers at the end.

Poor quality or fitting of the footwear.

Unhygienic appearance of foot.

Improper care of the nails of the toe.

Heavy intake of alcohols and tobacco.

Obesity and Weight-related

Complication arising from Diabetes like eye problems, kidney problems and more.

Although aging or old age can also be counted among them.

4. What sequence of stages of diabetes has been noted in this patient?

ANS:     alcohol------obesity------impaired glucose tolerance------diabetes mellitus------microvascular complications like triopathy and diabetic foot ulcer-------macrovascular complications like coronary artery disease , coronary vascular disease and peripheral vascular disease.

Link C:

https://preityarlagadda.blogspot.com/2021/05/biatrial-thrombus-in-52yr-old-male.html

1Q) what is the evolution of the symptomatology in this patient interms of an event timeline and where is the anatomical localisation for the problem and what is the primary etiology of the patient  problem ?

1Ans)Evolution of symptomatology

1st episode of sob - 20 yr back

2nd episode of sob - 12 yr back

From then she has been having yearly episodes for the past 12 yrs 

Diagnosed with diabetis - 8yrs back

Anemia and  took iron injections  - 5yr ago

Generalised weakness  - 1 month back 

Diagnosed with hypertension  - 20 days back

Pedal edema - 15 days back

Facial puffiness- 15 yrs back

Anatomical location of problem - lungs

Primary etiology of patient- usage  of chulha since 20 yrs might be due to chronic usage 

2Q)what r the mechanism of action indication and efficacy over placebo of each of the phramacological and nonphramacological interventions  used for this patient?

2Ans)~Head end elevation :# MOA;

.improves oxygenation 

.decreases incidence VAP

.increases hemodynamic performance 

.increases end expiratory lung volume

.decreases incidence of aspiration 

#Indication: .head injury

.meningitis 

.pneumonia 

~ oxygen inhalation to maintain spo2

~Bipap:non invasive method

#MOA :assist ventilation  by delivering positive expiratory and inspiratory pressure with out need for ET incubation9

3. Cause for current acute excerbation - it could be due any infection

4.could the ATT affected her symptoms if so how?

Yes ATT affected her symptoms

Isoniazid and rifampcin -nephrotoxic - raised RFT was seen

Neurology

https://neerajareddysingur.blogspot.com/2021/05/general-medicine-case-discussion.html?m=1

1) What can be  the cause of her condition ?     

   

According to MRI  cortical vein thrombosis might be the cause of her seizures.

            

2) What are the risk factors for cortical vein thrombosis?

Infections:

Meningitis, otitis,mastoiditis

Prothrombotic states:

Pregnancy, puerperium,antithrombin deficiency proteinc and protein s deficiency,Hormone replacement therapy.

Mechanical:

Head trauma,lumbar puncture

Inflammatory:

SLE,sarcoidosis,Inflammatory bowel disease. 

Malignancy.

Dehydration 

Nephrotic syndrome 

Drugs:

Oral contraceptives,steroids,Inhibitors of angiogenesis

Chemotherapy:Cyclosporine and l asparginase

Hematological:

Myeloproliferative Malignancies

Primary and secondary polycythemia

Intracranial :

Dural fistula, 

 venous anomalies 

Vasculitis:

Behcets disease wegeners granulomatosis

3)There was seizure free period in between but again sudden episode of GTCS why?resolved spontaneously  why?      

  Seizures are resolved and seizure free period got achieved after medical intervention but sudden episode of seizure was may be due to any persistence of excitable foci by abnormal firing of neurons.

             

4) What drug was used in suspicion of cortical venous sinus thrombosis?

Anticoagulants are used for the prevention of harmful blood clots.

Clexane  ( enoxaparin)  low molecular weight heparin binds and potentiates antithrombin three a serine protease Inhibitor  to form complex and irreversibly inactivates factor xa.

NEPHROLOGY

Link A

https://kavyasamudrala.blogspot.com/2021/05/medicine-case-discussion-this-is-online.html

 1.what could be the cause for his SOB

Ans- His sob was is due to Acidosis which was caused by Diuretics

2. Reason for Intermittent Episodes of drowsiness

 Ans-Hyponatremia was the cause for his drowsiness 

3.why did he complaint of fleshy mass like passage inurine

Ans-plenty of pus cells in his urine passage  appeared as

 fleshy mass like passage to him

4. What are the complicat ions of TURP that he may have had

Ans- 

       Difficulty micturition

        Electrolyte imbalances

         Infection

         Turp syndrome 



Link B

https://drsaranyaroshni.blogspot.com/2021/05/an-eight-year-old-with-frequent.html

1.Why is the child excessively hyperactive without much of social etiquettes ?

1ans* The exact pathophysiology of Attention Deficit Hyperactivity Disorder (ADHD) is not clear. With this said, several mechanisms have been proposed as factors associated with the condition. These include abnormalities in the functioning of neurotransmitters, brain structure and cognitive function.

* Due to the efficacy of medications such as psychostimulants and noradrenergic tricyclics in the treatment of ADHD, neurotransmitters such as dopamine and noradrenaline have been suggested as key players in the pathophysiology of ADHD.

 * Depressed dopamine activity has been associated with the condition,



2. Why doesn't the child have the excessive urge of urination at night time ?

2ans:the child doesn’t have the excessive urge of urination at night time because ADHD is a physcosomatic disorder 

3. How would you want to manage the patient to relieve him of his symptoms

3) TREATMENT





Infections diseases and Hepatology

Link A:

https://kavyasamudrala.blogspot.com/2021/05/liver-abscess.html

Liver abscess

1Q)do u think drinking locally  made alcohol cause liver abscess in this patient due to predisposing factors present in it ? What could be the cause in this patient?

1ans- yes, it could be due to intake of contaminated toddy

2Q)what is the etiopathogenesis of liver abscess  in a chronic alcoholic patient?(since 30 yrs - 1 bottle/day)

2ans - according to some studies, alcoholism mainly consuming locally prepared alcohol plays a major role as a predisposing factor for the formation of liver abscesses that is both amoebic as well as pyogenic liver abscess because of the adverse effects of alcohol over the Liver. It is also proven that Alcoholism is never an etiological factor for the formation of liver abscess.

3Q)is liver abscess is more common in right lobe?

 3ans-yes right lobe is involved due to its moreblood supply

4Q) what r the indications  for usg guided aspiration of liver abscess 

4ans- Indications for USG guided aspiration of liver abscess

1. Large abscess more than 6cms

2. Left lobe abscess

3.Caudate lobe abscess

4. Abscess which is not responding to drugs

INFECTIONS DISEASE

 (ophthalmology,otorhinolaryngology,mucormycosis)

Link A

http://manikaraovinay.blogspot.com/2021/05/50male-came-in-altered-sensorium.html

1:QUESTION:  What is the evolution of the symptomatology in this patient in terms of an event timeline and where is the anatomical localization for the problem and what is the primary aetiology of the patient's problem?

1.     Diagnosed with HTN -3yrs ago.

   21 days ago- received vaccination at local PHC which was followed by fever associated with chills and rigors, high grade fever, no diurnal variation which was relieved on medication

3.     18 days ago- complained of similar events and went to the the local hospital, it was not subsided upon taking medication(antipyretics) 

4.     11 days ago - c/o Generalized weakness and facial puffiness and periorbital oedema. Patient was in a drowsy state

5.     4 days ago-  

a.     patient presented to casualty in altered state with facial puffiness and periorbital oedema and weakness of right upper limb and lower limb

b.     towards the evening patient periorbital oedema progressed

c.     serous discharge from the left eye that was blood tinged

d.     was diagnosed with diabetes mellitus

6.     patient was referred to a government general hospital 

7.     patient died 2 days ago

Covid 

Case A

1) Since patient didn't show any previous characteristic diabetes signs, did the Covid-19 infection aggravate any underlying condition and cause the indolent diabetes to express itself? If so what could be the biochemical pathways that make it plausible?

novel coronavirus enters cell hosts through An- giotensin II Converting Enzyme receptor (ACE2). 

ACE2 receptor is found in the pancreas, both on exocri- ne cells and in the endocrine cells, that constitute pan- creatic islets. (8) Interestingly, its expression is also rele- vant in the endothelial cells of the microvasculature supplying beta-cells that produce insulin.

deficiency of this receptor compromises the vasculature in pancreatic islets, thus decreasing its endocrine function.

cytokine storm - caused by the severe inflammatory response taking place in the lungs - also targets the pancreas possibly causing diabe- tes 

2) Did the patient's diabetic condition influence the progression of her pneumonia?

COVID-19 and diabetes, but no other comorbidities (n = 24), were at higher risk for severe pneumonia, release of tissue injury-related enzymes, excessive uncontrolled inflammation responses and hypercoagulable state associated with dysregulation of glucose metabolism when compared with patients without diabetes.

3) What is the role of D Dimer in the monitoring of covid? Does it change management or would be considered overtesting? 

The D-dimer molecule is a product of the degradation of the fibrin protein. a biomarker-based evaluation which identifies the amount of ongoing coagulation at a given point of time .D-dimer has been shown to be an indicator for cardiac injury in COVID-19 patients in a setting of prothrombotic state

D-dimer may be able to predict which COVID-19 patients have poorer outcomes.

       Case b                             

1) How does the pre-existing ILD determine the prognosis of this patient?

 In patients with preexisting ILD, COVID-19 infection has led to acute exacerbation of underlying ILD. The criteria for ILD exacerbation include subacute worsening of dyspnea and hypoxemia, new pulmonary infiltrates on imaging, and absence of pulmonary emboli, cardiac failure, and other non-pulmonary causes. .Thus it leads to a poor prognosis

2) Given the history of autoimmune disease in the patient, how does the administration of steroids for COVID affect her RA and hypothyroidism? 

Corticosteroids are the cornerstone of for managing disease flares and for initial treatment of RA 

It is identified glucocorticoids as a significant risk factor for bacterial infections. Glucocorticoid use doubled the rate of serious bacterial infections in a dose-dependent manner as compared with methotrexate

It is concluded that there is no evidence to support its use in COVID-19, and it may in fact lead to more harm than good

3) Would this patient have an increased risk for post covid autoimmune response compared to patients without a history of autoimmune disease?

In Covid ,lymphoplasmocyte cell infiltrates are involved (mainly at the lung level), as well as the expression of pro-inflammatory cytokines such as interleukin (IL) IL-1, IL-6, IL-17, and TNF-α, and markers of systemic inflammation such as C-reactive protein or ferritin [34]. A parallelism of events was found with RA, where there are similar infiltrates at the synovial level, with expression of the same group of proinflammatory cytokines and elevation of acute-phase reactants [35]. However, this route is unlikely, given that there has been no increase in exacerbations of RA patients concomitantly suffering from COVID-19

4) Why was she prescribed clexane (enoxaparin)?

Clexane 60mg Injection is an anticoagulant used to prevent and treat harmful blood clots. It stops the existing clots from getting any bigger and restricts the formation of any new clot. It is also helpful in the prevention of blood clots in veins, a condition called deep vein thrombosis, and pulmonary embolism.

 

Patient was diagnosed with diabetic ketoacidosis and was unaware that he was diabetic until then. This resulted in poorly controlled blood sugar levels. The patient was diagnosed with acute oro rhino orbital mucormycosis . rhino cerebral mucormycosis is the most common form of this fungus.