EXAM

 Questions:

Please go through the patient data in the links below and answer the following questions:

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 ?

A 55 year old male, construction worker with Type2 DM, who is a chronic alcoholic & smoker, came with c/o weakness of right upper limb with involuntary movements of both right UL & LL 

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

 

Subcortical areas are supplied by penetrating branches that arise from initial segments of the arteries near the Circle of Willis at the base of the brain.Occlusion of these penetrating arteries result in subcortical infarcts. These penetrating arteries arise at acute angles from major vessels and are thus, anatomically prone to constriction and occlusion. So subcortical infarcts are more common than cortical infarct.

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 precordial leads V1 to V6

Yes,I agree with the team on starting Enoxaparin

 https://www.sciencedirect.com/science/article/pii/S0012369216329579

5. Which AED would you prefer?

Carbamazepine

If so why?

It binds preferentially to voltage-gated sodium channels in their inactive conformation, which prevents repetitive and sustained firing of an action potential.

Please provide studies on  efficacies of each of the treatment given to this patient.

https://pubmed.ncbi.nlm.nih.gov/29243813/

Question 2) 55 year old man with Recurrent hypoglycemia

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 Type2 DM came with c/o exertional dyspnea and cough since 3 days, patient complained of sudden onset of 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

Features of renal failure—> decreased excretion of OHAs—-> increased duration of action—> lead to hypoglycemia

 

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

Obesity might be the cause of dyspnoea because it increases the work load of breathing 

        albuminuria<—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.

 CUE/ urine cultures are not available,which would compliment the use of antibiotics.

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?

Efficacy and safety of various anti-rheumatic treatments for patients with rheumatoid arthritis:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6348345/

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

-Transfusion related acute hepatic injury (TRAHI)
-Post transfusion hepatitis

-Ischemic hepatitis

Evaluation:

https://www.researchgate.net/publication/12222410_Diagnosis_and_Monitoring_of_Hepatic_Injury_II_Recommendations_for_Use_of_Laboratory_Tests_in_Screening_Diagnosis_and_Monitoring

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 treatment

I agree with the treatment provided by the treating team 

• Lasix & Nebulization —for wheeze and crepts
• Lactulose —To prevent hepatic encephalopathy
• 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 Type2 DM presented with c/o pricking type of chest pain since 4 days and uncontrolled sugars with GRBS being 585 

Diagnosed of AKI with septic shock 

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

3. What are the chest xray findings?

Plain radiograph of chest 

Trachea shifted towards right
Consolidation noted in the right upper lobe 

Heart is central in position

Cardiac size normal

The domes of diaphragm are normal in position and smooth outline

Visualized bones appear normal

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

• Inflammation
• Malnutrition
• Albuminuria

Approach to hypoalbuminemia:

5. Comment on the treatment given along with each of their efficacies with supportive evidence.

• Piptaz & clarithromycin : for sepsis
• Egg white & protien powder : for hypoalbuminemia
• Lactulose : for constipation
• Actrapid / Mixtard : for hyperglycemia
• Tramadol : for pain
• 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 secondary to HBV

Kidney : AKI on CKD, Hyperkalemia

GI : GAVE,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)

Haemodialysis is performed by passing blood from a patient through a dialysis machine, and multiple patients receive dialysis within a dialysis unit. Therefore, there is a risk that these viruses may be transmitted around the dialysis session due to contamination.

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://pubmed.ncbi.nlm.nih.gov/11999818/

• Lasix : for fluid overload (AKI on CKD) 

• Vitamin -k 

• 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 came with  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.

 H/O Urinary urge incontinence since 6 months.

H/O Forgetfulness since 3 months.

He has delayed response to commands.

 H/O Dysphagia to both solids and liquids since 10 days.

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

Efficacy-https://pubmed.ncbi.nlm.nih.gov/12970516/

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 

H/o involuntary weight loss since 6 months , H/o headache since 2 months 

 4 - 5 episodes of involuntary stiffening of both UL & LL with 5 min LOC before seven days

Brain - multiple ring enhancing lesions in right cerebellum

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

Fungal

Actinoimycosis 

Histoplasmosis

Coccidioidomycosis

Paracoccidioidomycosis

Aspergillosis

Mucormycosis

Cryptococcosis

Bacterial

Pyogenic abscess

Tuberculoma and tuberculous abscess Mycobacterium avium-intracellulare infection Syphilis

Parasitic

Neurocysticercosis

Amoebic brain abscess

Echinococcosis

Chagas' disease

Toxoplasmosis

Neoplastic

Metastases

Primary brain tumor

Inflammatory and demyelinating

Multiple sclerosis

Sarcoidosis 

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?

Immune reconstitution inflammatory syndrome (IRIS) is a condition seen in some cases of AIDS or immunosuppression, in which the immune system begins to recover, but then responds to a previously acquired opportunistic infection with an overwhelming inflammatory response that paradoxically makes the symptoms of infection worse

WHO recommends that all HIV-infected TB patients should be commenced on ART irrespective of their CD4 count. This has the potential to reduce mortality. ART should be given within 8 weeks of initiation of antituberculosis treatment and based on the CAMELIA, SAPIT and STRIDE trials, in TB patients with a CD4 count of less than 50cells/mm3, ART should be started within 2 weeks after the onset of antituberculosis treatment.

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.

—pathogenesis of post stroke seizure

—Transfusion reactions

—Guidelines of hemodialysis management for patients infected with  blood borne viruses

—IRIS and ART in HIV-infected TB patients

—Drug induced hypoglycemia

—GAVE 

—Resistent hypertension treatment