General medicine Assignment

MEDICINE BLENDED ASSIGNMENT

May 24,2021

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, investigation and diagnosis and come up with the treatment plan.

This is the link of 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

CASE:1

1) 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 etiology of the patient's problem?

Evolution of symptomology:

20 yrs back-First episode of shortness of breath(lasted for 1 week during January)and continued in the same pattern for 7 years

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12 years back-Episode lasted for 20 days and continued in the same pattern till 30 days back

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Latest episode- lasted for 30 days and not getting relieved on medication

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Other symptoms

5 yrs ago-Anaemia

1 month back-Generalised weakness

20 days ago- Hypertension

15 days ago- pitting type of pedal edema and facial puffiness

Anatomical localization of the problem:

Bronchi and bronchioles of the lung

Primary etiology :

The symptoms are probably due to the inhalation of Paddy dust

Paddy dust is biologically composed of

plant material

fungi: of genus epicocum, fusarium

parts of insects: House dust mites and storage mites

bacteria

soil

Rice dust enters human airway(extrinsic antigen)

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It triggers and stimulate the plasma cells and lymphoid tissue to produce IgE

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IgE bind to mast cell and release Histamine and Bradykinin

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These narrow the respirator tract and increase of mucus production

2) What are mechanism of action, indication and efficacy over placebo of each of the pharmacological and non pharmacological interventions used for this patient?

1.Head and elevation: Significantly increases global and regional end-expiratory lung volume. It has also been shown to improve oxygenation and hemodynamic performance.

2.Bipap intermittent: By having a custom air pressure for when you inhale and a second custom air pressure when you exhale, the machine is able to provide relief to your overworked lungs and chest wall muscles.

3.inj.Augmentin

Augmentin is a prescription antibiotic medication. It’s used to treat infections caused by bacteria. Augmentin belongs to the penicillin class of antibiotics.Augmentin contains two drugs: amoxicillin and clavulanic acid. This combination makes Augmentin work against more types of bacteria than antibiotics that contain amoxicillin alone.Augmentin is effective for treating infections caused by many different types of bacteria. These include bacteria that cause:

pneumonia, ear infections, sinus infections,skin infections,urinary tract infections

4. Tab Azithromycin antibiotic

It's widely used to treat chest infections such as pneumonia, infections of the nose and throat such as sinus infection (sinusitis), skin infections, Lyme disease, and some sexually transmitted infections.

5. Inj lasix

Furosemide is used to reduce extra fluid in the body (edema) caused by conditions such as heart failure, liver disease, and kidney disease. This can lessen symptoms such as shortness of breath and swelling in your arms, legs, and abdomen.This drug is also used to treat high blood pressure.

6.Tab pantop

It is commonly used for the diagnosis or treatment of Gastro-esophageal reflux disease, Heartburn, Euophagus inflammation, Stomach ulcers.

7.Inj.Hydrocortisone

It is used to treat disorders of the skin, hormones, stomach, blood, nerves, eyes, kidneys, or lungs. They also include rheumatic disorders, allergic problems, certain cancers, or problems with the intestines such as ulcerative colitis.

8.Nebuliser with

A) ipravent: It is an anticholinergic bronchodilator. It is used in the Treatment of COPD and prevention of asthma

B)budecort: It is a corticosteroid and acts as an anti-asthmatic agent. It helps in controlling daily symptoms such as shortness of breath, wheezing and chest pain and prevents the worsening of these symptoms. Budecort should always be administered with the help of nebulisers. Nebuliser is a machine that forms a mist of medicine so that it can reach the lungs easily. Your doctor or pharmacist will guide you on how to use nebulisers properly. You should take Budecort regularly as advised by your doctor for effective control of your asthma

9. Tab pulmoclear

It contains a combination of two medicines, Acebrophylline and Acetylcysteine. They belong to the class of bronchodilators and mucolytics, respectively. It is used for relieving the symptoms of coughing, wheezing, congestion and blockage in the airways in a condition called chronic obstructive pulmonary disease (COPD).

10) Chest physiotherapy

It is a term used for a group of treatments designed to improve respiratory efficiency, promote expansion of the lungs, strengthen respiratory muscles, and eliminate secretions from the respiratory system.It includes postural drainage, chest percussion, chest vibration, turning, deep breathing exercises, and coughing.

11)Inj HAI SC

Human Actrapid 40IU/ml Solution for Injection is a short-acting insulin used to treat type 1 and type 2 diabetes mellitus. It is used together with a healthy diet and regular exercise to control blood sugar levels after meals. This helps to prevent serious complications of diabetes like kidney damage and blindness.

12) Inj thiamine

To treat or prevent thiamine(B1) insufficiency

13)Vitals charting

This allow for continuous monitoring of a patient, with medical staff being continuously informed of the changes in general condition of a patient.

14)I/O chart

Urine input/output chart

This chart (also known as a frequency-volume chart or bladder diary) is used to assess how much fluid you drink, to measure your urine volume, to record how often you pass urine over 24 hours and to show any episodes of incontinence (leakage)

15) O2 inhalation

It is used to

A) manage the condition of hypoxia

B)maintain o2 tension in blood plasma

C)increase oxy haemoglobin in RBC

D) maintain ability of cells to carry out normal metabolic function

E)reduce the risk of complications

3) What could be the causes for her current acute exacerbation?

Respiratory infection, being responsible for approximately half of COPD exacerbations. Common bacterial pathogens of acute exacerbations include Haemophilus influenzae, Streptococcus pneumoniae and Moraxella catarrhalis.[7]Less common bacterial pathogens include Chlamydia pneumoniae and MRSA.

Allergens, e.g., pollens, wood or cigarette smoke, pollution[5]

Toxins, including a variety of different chemicals[5]

Air pollution[citation needed]

Failing to follow a drug therapy program, e.g. improper use of an inhaler

4. Could the ATT have affected her symptoms? If so how?

There are some case reports about interstitial lung disease (ILD) such as pneumonitis caused by isoniazid (INH), rifampin (RFP), ethambutol (EMB). Therefore The causative drug was discontinued permanently or re-administrated after desensitization therapy.

5.What could be the causes for her electrolyte imbalance?

The distribution of electrolyte disturbances in COPD group (total 58.53%) was found as follows: hypokalemia in 20%, hyponatremia in 13.33%, hypomagnesemia in 6.66%, hypochloremia in 3.33%, and combined disturbances in 15%.

Activation of the renin-angiotensin-aldosterone system and inappropriately elevated plasma arginine vasopressin in COPD may aggravate the electrolyte imbalance during acute exacerbation of COPD

This patient has Hyponatremia and Hypochloremia according to the reports

Hyponatremia in patients with COPD developed secondary to many reasons, such as development or worsening of hypoxia, hypercapnia, and respiratory acidosis, and right-side heart failure with development of lower limb edema, renal insufficiency, use of diuretics

respiratory acidosis with metabolic alkalosis (owing to renal compensation) in patients with COPD with chronic hypercapnia is the usual cause of hypochloremia in those patients.

NEUROLOGY

CASE 2A

A 40year old male presented with chief complaints of irrelevant talking and decreased food intake since 9days.

He was conscious but oriented to time, person and place only from time to time.

He also had short term memory loss since 9days, where he couldn't recognize family members from time to time

Previously, he had 2-3episodes of seizures, one being one year ago and the most recent being 4months ago. The most recent one, he had developed seizures following cessation of alcohol for 24hours.

1) what is the evolution of the symptomology in this patient in terms of an event timeline and where is the anatomical localization for the problem and what is the primary etiology of the patient's problem?

Ans: The patient is a chronic alcoholic, he drinks about 3-4quarters/day.he had developed seizures following the cessation of alcohol for 24hours it is due to the following reason:-alcohol affects the way in which nerve cells communicate. receptors are specialized proteins on the surface of nerve cells that receive chemical signals from one another. With long-term alcohol consumption, receptors affected by alcohol undergo adaptive changes in an attempt to maintain normal function.

Two important brain communication systems affected by alcohol involve the neurotransmitters:gamma-aminobutyric acid and glutamate.

The GABA system:

GABA is an inhibitory neurotransmitter that helps to regulate brain function by rendering nerve cells less sensitive to further signaling. single doses of alcohol facilitate the inhibitory function of the GABA receptor, contributing to alcohol intoxicating effects. During withdrawal, brain GABA levels fall below normal and GABA activity declines. The combination of reduced brain GABA levels and GABAa receptor sensitivity may be contributed an adaptation to the presence of alcohol. In the absence of alcohol, the resulting decrease in inhibitory function may contribute to Symptoms of nervous system hyperactivity associated with both acute and protracted AW.

The glutamate system:

The major excitatory neurotransmitter in the brain is glutamate, which communicates with three major subtypes of glutamate receptors. Among these, the N-methyl-D-aspartate (NMDA) receptor plays a role in memory, learning, and the generation of seizures. Alcohol inhibits the excitatory function of the NMDA receptor in laboratory studies at concentrations associated with mild to moderate alcohol intoxication in humans. As with the increased inhibitory function of the GABAA receptor, the decreased excitatory function of the NMDA receptor is consistent with alcohol’s general sedative effect. Long-term alcohol administration produces an adaptive increase in the function of NMDA receptors. Acute AW activates glutamate systems. In turn, AW seizures are associated with increased NMDA receptor function. Persistent alterations in NMDA receptor function may potentiate the neurotoxic and seizure-inducing effects of increased glutamate release during withdrawal.

The symptom: irrelevant talking, decreased food intake, tremors, sleep disturbance is due to the following reason: chronic alcohol consumption causes thiamine deficiency due to impaired absorption of thiamine from the intestine, a possible genetic predisposition, inadequate diet, reduced storage of thiamine in the liver and other nutritional deficiencies.

THE PATHOPHYSIOLOGY:

Thiamine, one of the first B vitamins to be discovered also known as Vitamin B1, is a coenzyme that is essential for intricate organic pathways and plays a central role in cerebral metabolism. This vitamin acts as a cofactor for several enzymes in the Krebs cycle and the pentose phosphate pathway, including alpha-keto-glutamic acid oxidation and pyruvate decarboxylation. Thiamine-dependent enzymes function as a connection between glycolytic and citric acid cycles. Therefore, deficiency of thiamine will lead to decreased levels of alpha-keto-glutarate, acetate, citrate, acetylcholine and accumulation of lactate and pyruvate. This deficiency can cause metabolic imbalances leading to neurologic complications including neuronal cell death. Neuronal death in the mammillary bodies and thalamus were implicated in multiple cases of Wernicke encephalopathy studied. Studies involving computed tomography (CT) and magnetic resonance imaging (MRI) of patients with Wernicke encephalopathy revealed lesions in the thalamus with dilated ventricles and volume loss in the mammillary bodies. The lesions are usually symmetrical in the midbrain, hypothalamus, and cerebellum.

The kidneys have an important job as a filter for harmful substances .alcohol causes changes in the function of the kidneys and makes them less able to filter the blood .alcohol also affects the ability to regulate fluid and electrolytes in the body. In addition, alcohol can disrupt hormones that disrupt hormones that affect kidney function .people who drink too much are more likely to have high blood pressure. High blood pressure is a common cause of kidney disease. The increase in levels of urea, creatinine, uric acid leads to uraemic encephalopathy. which causes asterixis.

the deficiency of thiamine and increase in levels of toxins in the body due to renal disease is the primary etiology of the patient's problem.

2)what are the mechanism of action, indication, and efficacy over placebo of each of the pharmacological and nonpharmacological interventions used for this patient?

Ans: I) Thiamine helps the body cells change carbohydrates into energy. It has been used

as a supplement to cope with thiamine deficiency

ii)Lorazepam binds to benzodiazepine receptors on the postsynaptic GABA-A ligand-gated chloride channel neuron at several sites within the central nervous system.it enhances the inhibitory effects of GABA, which increases the conductance of chloride ions into the cell

iii)pregabalin subtly reduces the synaptic release of several neurotransmitters, apparently by binding to alpha2-delta subunits, and possibly accounting for its actions invivo to reduce neuronal excitability and seizures.

iv)Lactulose is used in preventing and treating clinical portal-systemic encephalopathy .its chief mechanism of action is by decreasing the intestinal production and absorption of ammonia.

v)Potchlor liquid is used to treat low levels of potassium in the body.

3)why have neurological symptoms appeared this time, that were absent during withdrawal earlier ? what could be a possible cause for this time?

Due to excess thiamine deficiency and excess toxins accumulation due to renal disease caused by excess alcohol addiction.

4)what is the reason for giving thiamine in this patient?

chronic alcohol consumption causes thiamine deficiency due to impaired absorption of thiamine from the intestine,Thiamine, one of the first B vitamins to be discovered also known as Vitamin B1, is a coenzyme that is essential for intricate organic pathways and plays a central role in cerebral metabolism. This vitamin acts as a cofactor for several enzymes in the Krebs cycle and the pentose phosphate pathway, including alpha-keto-glutamic acid oxidation and pyruvate decarboxylation. Thiamine-dependent enzymes function as a connection between glycolytic and citric acid cycles. Therefore, deficiency of thiamine will lead to decreased levels of alpha-keto-glutarate, acetate, citrate, acetylcholine, and accumulation of lactate and pyruvate. This deficiency can cause metabolic imbalances leading to neurologic complications including neuronal cell death.

5)what is the probable cause for kidney injury in this patient?

6)what is the probable cause for the normocytic anaemia?

alcohol causes iron deficiency or iron overload due its affect on production of new blood cells organs i.e,bonemarrow and the metabolism of iron .alocohol causes a affect on progenitor cells of blood causing decreased WBC .RBC.alochol decreases iron absorption from intestine .

7)could chronic alcohlism have aggravated the foot ulcer formation ?if yes and why ?

yes,As the patient is diabetic the chance of ulcer formation increases .in a patient of chronic alcoholic theimmune system is weak due to the affect on blood cells formation and iron absorption.due to this healing of an ulcer dampens.

CASE 2B

1) What is the evolution of the symptomology in this patient in terms of an event timeline and where is the anatomical localization for the problem and what is the primary etiology of the patients problem?

ANS. Timeline of the patient is as follows-

7 days back- Patient gave a history of giddiness that started around 7 in the morning; subsided upon taking rest; associated with one episode of vomiting

4 days back- Patient consumed alcohol; He developed giddiness that was sudden onset, continuous and gradually progressive. It increased on standing and while walking.

H/O postural instability- falls while walking

Associated with bilateral hearing loss, aural fullness, presence of tinnitus

Associated vomiting- 2-3 episodes per day, non projectile, non bilious without food particles

Present day of admission- Slurring of speech, deviation of mouth that got resolved the same day

Anatomical location- There is a presence of an infarct in the inferior cerebellar hemisphere of the brain.

Etiology- Ataxia is the lack of muscle control or co-ordination of voluntary movements, such as walking or picking up objects. This is usually a result of damage to the cerebellum (part of the brain that controls muscle co-ordination)

Many conditions cause cerebellar ataxia- Head trauma, Alcohol abuse, certain medications eg. Barbituates, stroke, tumours, cerebral palsy, brain degeneration etc.

In this case, the patient has hypertension for which he has been prescribed medication that he has not taken. Stroke due to an infarct can be caused by blockade or bleeding in the brain due to which blood supply to the brain is decreased, depriving it of essential oxygen and nutrients. This process could’ve caused the infarct formation in the cerebellar region of the brain, thus causing cerebellar ataxia.

2) What are the mechanism of action, indication and efficacy over placebo of each of the pharmacological and non pharmacological interventions used for this patient?

ANS.

A) Tab Vertin 8mg- This is betahistine, which is an anti- vertigo medication

MOA- It is a weak agonist on H1 receptors located on blood vessels of the inner ear. This leads to local vasodilation and increased vessel permeability. This can reverse the underlying problem.

Indications- Prescribed for balance disorders. In this case it is used due to patients history of giddiness and balance issues.

B) Tab Zofer 4mg- This is ondanseteron- It is an anti emetic

MOA- It is a 5H3 receptor antagonist on vagal afferents in the gut and they block receptors even in the CTZ and solitary tract nucleus.

Indications- Used to control the episodes of vomiting and nausea in this patient.

C) Tab Ecosprin 75mg- This is aspirin. It is an NSAID

MOA- They inhibit COX-1 and COX-2 thus decreasing the prostaglandin level and thromboxane synthesis

Indications- They are anti platelet medications and in this case used to prevent formation of blood clots in blood vessels and prevent stroke.

D) Tab Atorvostatin 40mg- This is a statin

MOA- It is an HMG CoA reductase inhibitor and thus inhibits the rate limiting step in cholesterol biosynthesis. It decreases blood LDL and VLDL, decreases cholesterol synthesis, thus increasing LDL receptors in liver and increasing LDL uptake and degeneration. Hence plasma LDL level decreases.

Indications- Used to treat primary hyperlipidemias. In this case it is used for primary prevention of stroke.

E) Clopidogrel 75mg- It is an antiplatelet medication

MOA- It inhibits ADP mediated platelet aggregation by blocking P2Y12 receptor on the platelets.

Indications- In this case it decreases the risk of heart disease and stroke by preventing clotting

F) Thiamine- It is vitamin B1

It is naturally found in many foods in the human diet. In this case, the patient consumes excess alcohol- so he may get thiamine deficiency due to poor nutrition and lack of essential vitamins due to impaired ability of the body to absorb these vitamins.

Indications- Given to this patient mainly to prevent Wernickes encephalopathy- that can lead to confusion, ataxia and opthalmoplegia.

G) Tab MVT- This is methylcobalamin

Mainly given in this case for vitamin B12 deficiency.

3) Did the patients history of denovo hypertension contribute to his current condition?

ANS. A cerebellar infarct is usually caused by a blood clot obstructing blood flow to the cerebellum. High blood pressure that is seen in hypertension (especially if left untreated) can be a major risk factor for the formation of cerebellar infarcts.

Increased shear stress is caused on the blood vessels. The usual adaptive responses are impaired in this case, thus leading to endothelial dysfunction in this case. High BP can also promote cerebral small vessel disease. All these factors contribute to eventually lead to stroke.

4) Does the patients history of alcoholism make him more susceptible to ischaemic or haemorrhagic stroke?

ANS. Meta analysis of the relation between alcohol consumption and increased risk of stroke has mainly weighed in to the formation of two types- ischaemic and haemorrhagic stroke.

Ischaemic stroke- this is more common. This Is caused by a blood clot blocking the flow of blood and preventing oxygen from reaching the brain

Haemorrhagic stroke- occurs when an aneurysm bursts or when a weakened blood vessel leaks, thus causing cerebral haemorrhage

According to a Cambridge study, heavy drinkers have 1.6 more chance of intracerebral haemorrhage and a 1.8 increased chance of subaracnoid haemorrhage. The adverse effect on BP that is seen due to increased drinking is a major stroke risk factor and increase the risk of heart stroke.

Many studies show that with mild and moderate drinking . the risk of ischaemic stroke decreases due to decreased level of fibrinogen which helps in the formation of blood clots. However, heavy alcohol intake is associated with impaired fibrinolysis, increased platelet activation and increased BP and heart rate.

So In this case, his history of alcoholism, coupled with his hypertension definitely could be a causative factor of his current condition.

CASE 2D

1.Is there any relationship between occurrence of seizure to brain stroke. If yes what is the mechanism behind it?

seizures after ischaemic strokes. An increase in intracellular Ca2+ and Na+ with a resultant lower threshold for depolarisation, glutamate excitotoxicity, hypoxia, metabolic dysfunction, global hypoperfusion, and hyperperfusion injury

Seizures after haemorrhagic strokes are thought to be attributable to irritation due to (hemosideri. Deposits)caused by products of blood metabolism

Late onset seizures are associated with the persistent changes in neuronal excitability and gliotic scarring is most probably the underlying cause.

2. In the previous episodes of seizures, patient didn't loose his consciousness but in the recent episode he lost his consciousness what might be the reason?

Initially the patient might have had Simple partial seizures (no loss of consciousness) and might have progressed to Generalised Tonic Clonic seizures (loss of consciousness)

CASE 2C

10 years back-Paralysis of both upper and lower limbs bilateral

1 year back-Right and left paresis due to hypokalemia

8 months backSwelling over legs

7 months back - blood infection

2 months back- neck pain

6 days back- pain along left upper limb

5 days back- chest pain, Difficulty in breathing and was able to feel her own heart beat

Anatomical localization: Cervical spine

degenerative changes that occur in the cervical spine with age.

Dehydrated disks. Disks act like cushions between the vertebrae of your spine. By the age of 40, most people's spinal disks begin drying out and shrinking, which allows more bone-on-bone contact between the vertebrae.

Bone spurs. Disk degeneration often results in the spine producing extra amounts of bone in a misguided effort to strengthen the spine. These bone spurs can sometimes pinch the spinal cord and nerve roots.

Herniated disks. Age also affects the exterior of your spinal disks. Cracks often appear, leading to bulging (herniated) disks — which sometimes can press on the spinal cord and nerve roots.

Stiff ligaments. Ligaments are cords of tissue that connect bone to bone. Spinal ligaments can stiffen with age, making your neck less flexible.

2) What are the reasons for recurrence of hypokalemia in her? Important risk factors for her hypokalemia?

Reasons for recurrence

The primary hypokalemic periodic paralysis is autosomal dominant and is exacerbated by strenuous exercise, high carbohydrate diet, cold and excitement, which was not found in this case. secondary periodic hypokalemic paralysis have been reported in association with gastroenteritis, diuretic abuse, renal tubular acidosis, Bartter syndrome, villous adenoma of colon, and hyperthyroidism.

Risk factors

Female [1] [2]

Medications like diuretics

Heart failure

Hypertension

Low BMI [3]

Eating disorder and alcoholism: low intake of potassium

Diarrhea, cushing syndrome, a

3) What are the changes seen in ECG in case of hypokalemia and associated symptoms?

ECG changes include flattening and inversion of T waves in mild hypokalemia, followed by Q-T interval prolongation, visible U wave and mild ST depression4 in more severe hypokalemia.

CASE 2E

1) What could have been the reason for this patient to develop ataxia in the past 1 year?

Ans: the reason for patient to develop ataxia in past one year is ALCOHOL

The toxic effects of alcohol are diverse. Alcohol-related cerebellar degeneration is one of the commonest causes of acquired cerebellar ataxia(ALCOHOL INDUCED TOXIC ATAXIA).

The pathophysiology remains unclear but proposed mechanisms include excitotoxicity, dietary factors, oxidative stress, compromised energy production and cell death

2) What was the reason for his IC bleed? Does Alcoholism contribute to bleeding diatheses ?

Ans: the reason for IC bleed is

CHRONIC ALCOHOL CONSUMPTION

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ALCOHOL INDUCED TOXIC ATAXIA

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REPEATED FALLS

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IC BLEEDING

* The impaired platelet function, together with the reduced platelet count, may contribute to the bleeding diathesis associated with chronic alcoholism and to the increased incidence and recurrence of gastrointestinal haemorrhage associated with excessive alcohol intake.

CASE 2F

1.Does the patient's history of road traffic accident have any role in his present condition?

A:One cause of stroke after trauma is a tear in the head or neck blood vessels that lead to the brain, which can be a source of blood clots that cause a stroke. If a tear in these arteries can be diagnosed at the time of the trauma, a patient could be treated with an anti-clotting medicine to help prevent stroke

2.What are warning signs of CVA?

3.What is the drug rationale in CVA?

3ans

Aspirin -antiplatlet drug prevents stroke

Atorvostatin - decreases LDL cholesterol to prevent recurrent attacks of stroke

4. Does alcohol has any role in his attack?

ans : Excessive alcohol consumption has been associated with a wide range of medical conditions. Moderate alcohol consumption is linked to a lower risk of stroke than abstinence, whereas heavy alcohol consumption has been associated with an increased risk of stroke and stroke mortality. In addition to alcohol consumption, the most important risk factors for stroke are hypertension, coronary artery disease, cardiac insufficiency, atrial fibrillation, type 2 diabetes, smoking, overweight, asymptomatic carotid artery stenosis and elevated levels of cholesterol.

5.Does his lipid profile has any role for his attack??

5ans

Yes increased LDL causes atherosclerosis -Blood vessels - ischemia leads to - stroke

CASE 2G

a)what is myelopathy hand?There is loss of power of adduction and extension of the ulnar two or three fingers and an inability to grip and release rapidly with these fingers. These changes have been termed "myelopathy hand" and appear to be due to pyramidal tract involvement.

b)what is finger escape?

Finger escape

Wartenberg's sign is a neurological sign consisting of involuntary abduction of the fifth (little) finger, caused by unopposed action of the extensor digiti minimi. . This finding of weak finger adduction in cervical myelopathy is also called the "finger escape sign".

c)what is Hoffman's sign?

Hoffman's sign or reflex is a test used to examine the reflexes of the upper extremities. This test is a quick, equipment-free way to test for the possible existence of spinal cord compression from a lesion on the spinal cord or another underlying nerve condition

CASE 2H

1) What can be the cause of her condition ?

the cause of her condiion could be IRON DEFICENCY ANEMIA.

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

Ans: Risk factors for children and infants include:

Problems with the way their blood forms clots

Sickle cell anemia

Chronic hemolytic anemia

Beta-thalassemia major

Heart disease — either congenital (you're born with it) or acquired (you develop it)

Iron deficiency

Certain infections

Dehydration

Head injury

For newborns, a mother who had certain infections or a history of infertility

Risk factors for adults include:

Pregnancy and the first few weeks after delivery

Problems with blood clotting; for example, antiphospholipid syndrome, protein C and S deficiency, antithrombin III deficiency, lupus anticoagulant, or factor V Leiden mutation

Cancer

Collagen vascular diseases like lupus, Wegener’s granulomatosis, and Behcet syndrome

Obesity

Low blood pressure in the brain (intracranial hypotension)

Inflammatory bowel disease like Crohn’s disease or ulcerative colitis

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

Ans: there was a sezuire free period due to administration of antiepileptic drugs as the effect of drugs weans off the sezures appear again followed by administration of phenobarbitone leading to spontaneous resolution of the sezuires.

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

Ans: heparin as CLEXANE was given to relive clot in suspission of CVS

CARDIOLOGY

CASE 3A

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

Ans:Preserved ejection fraction (HFpEF) – also referred to as diastolic heart failure. The heart muscle contracts normally but the ventricles do not relax as they should during ventricular filling (or when the ventricles relax).

Reduced ejection fraction (HFrEF) – also referred to as systolic heart failure

HFpEF is preceded by chronic comorbidities, such as hypertension, type 2 diabetes mellitus (T2DM), obesity, and renal insufficiency, whereas HFrEF is often preceded by the acute or chronic loss of cardiomyocytes due to ischemia, a genetic mutation, myocarditis, or valvular disease

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

Ans: Pericardiocentesis is not done here Because the effusion was self healing ,It reduced from 2.4cm to 1.9 cm.

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

Ans: risk factors for development of heart faliure in this patent

Alcohol abuse increases the risk of atrial fibrillation, heart attack and congestive heart failure

high blood pressure

Smoking

Diabetes

AV block can be associated with severe bradycardia and hemodynamic instability. It has a greater risk of progressing to third-degree (complete) heart block or asystole.

wosening of pericardial effusion leaing to cardiac tamponade.

4.What could be the cause for hypotension in this

Ans : visceral pericardium may have thickened which is restricting the heart to expand causing hypotension

(May be secondary to TB)

CASE 3B

QUESTION: What are the possible causes for heart failure in this patient?

the patient has various comorbidities which could have led to a heart failure

1. The patient was diagnosed with type 2 diabetes mellitus 30 years ago and has been taking human mixtrad insulin daily and was also diagnosed with diabetic triopathy indicating uncontrolled diabetes which is major risk factor for heart failure

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5494155/

2. The patient was also diagnosed with hypertension 19 yrs. ago which is also a risk factor for heart failure

https://pubmed.ncbi.nlm.nih.gov/31472888/

3. He is a chronic alcoholic since 40 years which is a risk factor towards heart failure

https://www.nmcd-journal.com/article/S0939-4753(19)30360-6/fulltext

The findings in this article provide longitudinal evidence that moderate and heavy alcohol consumption are associated with decreased LVEF and trend towards a higher risk of incident LV systolic dysfunction, compared to light drinkers.

4. The patient has elevated creatinine and AST/ALT ratios is >2 and was diagnosed with chronic kidney disease stage IV. CKD is also one of the risk factors for heart failure

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2900793/

QUESTION: what is the reason for anaemia in this case?

The patient has normocytic normochromic anaemia. it could be anaemia of a chronic disease as the patient is diagnosed with CKD stage IV.

Chronic kidney disease results in decreased production of erythropoietin which in turn decreases the production of red blood cells from the bone marrow.

Patient’s with anaemia and CKD also tend to have deficiency in nutrients like iron, vitamin B12 and folic acid essential in making healthy red blood cells

QUESTION: What is the reason for blebs and non-healing ulcer in the legs of this patient?

The most common cause for blebs and non-healing ulcer in this patient is diabetes mellitus. CKD is also known to cause delay in healing of wounds along with poorly controlled diabetes. Anaemia can also slow down the process of healing due to low oxygen levels.

QUESTION: What sequence of stages of diabetes has been noted in this patient?

There are 4 stages in type 2 diabetes- insulin resistance, prediabetes, type 2 diabetes and type 2 diabetes and vascular complications, including retinopathy, nephropathy or neuropathy and, or, related microvascular events.

The patient is diagnosed with diabetic triopathy exhibiting sequence of neuropathy, retinopathy and nephropathy

The patient has been diagnosed with diabetic retinopathy, CKD stage IV and shows signs of diabetic neuropathy such as numbness

CASE 3C

Ans: *the anatomical site is BLOOD VESSELS;

* ETIOLOGY:

The physical stress of hypertension on the arterial wall also results in the aggravation and acceleration of atherosclerosis, particularly of the coronary and cerebral vessels. Moreover, hypertension appears to increase the susceptibility of the small and large arteries to atherosclerosis.

The most likely cause of arterial thrombosis is artery damage due to atherosclerosis. Atherosclerosis occurs when a person has a buildup of plaque on the walls of their arteries. The arteries then begin to narrow and harden, which increases a person's risk of developing arterial thrombosis.

2) What are mechanism of action, indication and efficacy over placebo of each of the pharmacological and non pharmacological interventions used for this patient?

Ans: PHARMACOLOGICAL INTERVENTIONS

1. TAB. Dytor

mechanism: Through its action in antagonizing the effect of aldosterone, spironolactone inhibits the exchange of sodium for potassium in the distal renal tubule and helps to prevent potassium loss.

2. TAB. Acitrom

mechanism: Acenocoumarol inhibits the action of an enzyme Vitamin K-epoxide reductase which is required for regeneration and maintaining levels of vitamin K required for blood clotting

3. TAB. Cardivas

mechanism:Carvedilol works by blocking the action of certain natural substances in your body, such as epinephrine, on the heart and blood vessels. This effect lowers your heart rate, blood pressure, and strain on your heart. Carvedilol belongs to a class of drugs known as alpha and beta-blockers.

4. INJ. HAI S/C

MECHANISM:Regulates glucose metabolism

Insulin and its analogues lower blood glucose by stimulating peripheral glucose uptake, especially by skeletal muscle and fat, and by inhibiting hepatic glucose production; insulin inhibits lipolysis and proteolysis and enhances protein synthesis; targets include skeletal muscle, liver, and adipose tissue

5.TAB. Digoxin

mechanism:

Digoxin has two principal mechanisms of action which are selectively employed depending on the indication:

Positive Ionotropic: It increases the force of contraction of the heart by reversibly inhibiting the activity of the myocardial Na-K ATPase pump,

an enzyme that controls the movement of ions into the heart.

6. Hypoglycemia symptoms explained

7. Watch for any bleeding manifestations like Petechiae, Bleeding gums.

8. APTT and INR are ordered on a regular basis when a person is taking the anticoagulant drug warfarin to make sure that the drug is producing the desired effect.

3) What is the pathogenesis of renal involvement due to heart failure (cardio renal syndrome)? Which type of cardio renal syndrome is this patient?

Ans: *cardiorenal syndrome type 4 is seen in this patient.

4) What are the risk factors for atherosclerosis in this patient?

Ans: effect of hypertention

They can also impair blood vessels' ability to relax and may stimulate the growth of smooth muscle cells inside arteries. All these changes can contribute to the artery-clogging process known as atherosclerosis.

5) Why was the patient asked to get those APTT, INR tests for review?

Ans: APTT and INR are ordered on a regular basis when a person is taking the anticoagulant drug warfarin to make sure that the drug is producing the desired effect.

Here, an INR of 3-4.5 is recommended. Warfarin should be started in conjunction with heparin or low molecular weight heparin when the diagnosis of venous thromboembolism is confirmed, although local protocols may vary in their starting doses and titration schedule.

CASE 3D

TIMELINE OF EVENTS-

• Diabetes since 12 years - on medication

• Heart burn like episodes since an year- relieved without medication

• Diagnosed with pulmonary TB 7 months ago- completed full course of treatment, presently sputum negative.

• Hypertension since 6 months - on medication

• Shortness of breath since half an hour-SOB even at rest

Anatomical localisation - Cardiovascular system

Etiology: The patient is both Hypertensive and diabetic , both these conditions can cause

- Atherosclerosis: there is build up of fatty and fibrous material inside the wall of arteries.(PLAQUE)

2) What are mechanism of action, indication and efficacy over placebo of each of the pharmacological and non pharmacological interventions used for this patient?

Pharmacological interventions:

TAB MET XL 25 MG/STAT-contains Metoprolol as active ingredient

MOA: METOPROLOL is a cardiselective beta blocker

Beta blockers work by blocking the effects of the hormone epinephrine, also known as adrenaline. Beta blockers cause your heart to beat more slowly( negative chronotropic effect)

and with less force( negative inotropic effect). Beta blockers also help open up your veins and arteries to improve blood flow.

Indications: it is used to treat Angina, High blood pressure and to lower the risk of hear attacks .

EFFICACY STUDIES.

Patients were randomized to one of four treatment arms: placebo or ER metoprolol (0.2 mg/kg, 1.0 mg/kg, or 2.0 mg/kg). Data were analyzed on 140 intent-to-treat patients.

Results: mean baseline BP was 132/78 +/- 9/9 mmHg. Following 4 weeks of treatment, mean changes in sitting BP were: placebo = -1.9/-2.1 mmHg; ER metoprolol 0.2 mg/kg = -5.2/-3.1 mmHg; 1.0 mg/kg = -7.7/-4.9 mmHg; 2.0 mg/kg = -6.3/-7.5 mmHg. Compared with placebo, ER metoprolol significantly reduced systolic blood pressure (SBP) at the 1.0 and 2.0 mg/kg dose (P = .027 and P = .049, respectively), reduced diastolic blood pressure (DBP) at the 2.0 mg/kg dose (P = .017), and showed a statistically significant dose response relationship for the placebo-corrected change in DBP from baseline. There were no serious adverse events or adverse events requiring study drug discontinuation among patients receiving active therapy.

Non pharmacological intervention advised to this patient is: PERCUTANEOUS CORONARY INTERVENTION.

Percutaneous Coronary Intervention is a non-surgical procedure that uses a catheter (a thin flexible tube) to place a small structure called a stent to open up blood vessels in the heart that have been narrowed by plaque buildup ( atherosclerosis).

3) What are the indications and contraindications for PCI?

INDICATIONS:

Acute ST-elevation myocardial infarction (STEMI)

Non–ST-elevation acute coronary syndrome (NSTE-ACS)

Unstable angina.

Stable angina.

Anginal equivalent (eg, dyspnea, arrhythmia, or dizziness or syncope)

High risk stress test findings.

CONTRAINDICATIONS:

Intolerance for oral antiplatelets long-term.

Absence of cardiac surgery backup.

Hypercoagulable state.

High-grade chronic kidney disease.

Chronic total occlusion of SVG.

An artery with a diameter of <1.5 mm.

4) What happens if a PCI is performed in a patient who does not need it? What are the harms of overtreatment and why is research on overtesting and overtreatment important to current healthcare systems?

Although PCI is generally a safe procedure , it might cause serious certain complications like

A)Bleeding

B) Blood vessel damage

C) Allergic reaction to the contrast dye used

D) Arrhythmias

E) Need for emergency coronary artery bypass grafting .

Because of all these complications it is better to avoid PCI in patients who do not require it.

⁃ OVER TESTING AND OVER TRAETMENT HAVE BECOME COMMMIN IN TODAY’S MEDICAL PRACTICE.

⁃ Research on overtesting and overtreatment is important as they are more harmful than useful.

Harms to patients

. Performing screening tests in patients with who at low risk for the disease which is being screened.

For example:Breast Cancer Screenings Can Cause More Harm Than Good in Women Who Are at Low Risk. A harmless lump or bump could incorrectly come up as cancer during routine breast screenings. This means that some women undergo surgery, chemotherapy or radiation for cancer that was never there in the first place.

.Overuse of imaging techniques such as X- RAYS AND CT SCANS as a part of routine investigations.

Overuse of imaging can lead to a diagnosis of a condition that would have otherwise remained irrelevant - OVERDIAGNOSIS.

Also the adverse effects due to this are more when compared to the benefits.

.Overdiagnosis through overtesting can psychologically harm the patient.

Hospitalizations[41] for those with chronic conditions who could be treated as outpatients[ can lead to economic burden and a feeling of isolation.

Harms to health care systems

The use of expensive technologies and machineries are causing burden on health care systems.

CASE 3E

Ans: *the anatomical location ofetiology is BLOOD VESSELS.

*myocardial infarction is usually due to thrombotic occlusion of a coronary vessel caused by rupture of a vulnerable plaque. Ischemia induces profound metabolic and ionic perturbations in the affected myocardium and causes rapid depression of systolic function

2) What are mechanism of action, indication and efficacy over placebo of each of the pharmacological and non pharmacological interventions used for this patient?

Ans: PHARMACOLOGICAL INNTERVENTION

1.TAB. ASPIRIN

mechanism:Aspirin inhibits platelet function through irreversible inhibition of cyclooxygenase (COX) activity. Until recently, aspirin has been mainly used for primary and secondary prevention of arterial antithrombotic events.

2.TAB ATORVAS

mechanism:Atorvastatin competitively inhibits 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase. By preventing the conversion of HMG-CoA to mevalonate, statin medications decrease cholesterol production in the liver.

3.TAB CLOPIBB

mechanism:The active metabolite of clopidogrel selectively inhibits the binding of adenosine diphosphate (ADP) to its platelet P2Y12 receptor and the subsequent ADP- mediated activation of the glycoprotein GPIIb/IIIa complex, thereby inhibiting platelet aggregation. This action is irreversible.

4.INJ HAI

mechanism:Regulates glucose metabolism

5.ANGIOPLASTY

mechanism:Angioplasty, also known as balloon angioplasty and percutaneous transluminal angioplasty (PTA), is a minimally invasive endovascular procedure used to widen narrowed or obstructed arteries or veins, typically to treat arterial atherosclerosis.

3) Did the secondary PTCA do any good to the patient or was it unnecessary?

Ans:the second PCI was NOT necessary in this patient.

PCI performed from 3 to 28 days after MI does not decrease the incidence of death, reinfarction or New York Heart Association (NYHA) class IV heart failure but it is associated with higher rates of both procedure-related and true ST elevation reinfarction.3 A retrospective analysis of the clinical data revealed The Thrombolysis in Myocardial Infarction (TIMI) Risk Score of 4 predicting a 30-day mortality of 7.3% in this patient. Late PCI leads to the increased risks of periprocedural complications, long-term bleeding, and stent thrombosis.

The high incidence of CAD and the increasing need for PCI provides an opportunity to evaluate its appropriate use and highlight potential overuse. PCI is frequently reported to be overused and inappropriately recommended. Behnke et al defined overuse as ‘use of unnecessary care when alternatives may produce similar outcomes, resulting in a higher cost without increased value’.8Overuse causes a heavy financial burden on people living in countries, where fee-for-service and ill-regulated private healthcare provides much of the patient care. As a result, cost of healthcare increases and causes potential harm to the patients.

CASE 3F

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 etiology of the patient's problem?

Ans: Facial puffiness ( since 2 to 3 yrs)

Sob grade 2( 1yr ago)

Sob grade 2( 2days back again)

Sob grade 4

Decreased urine output ( since 2 days)

Anuria (since morning)

2. What are mechanism of action, indication and efficacy over placebo of each of the pharmacological and non pharmacological interventions used for this patient?

Ans: Dobutamine MOA: acts on beta 1 receptor

Beta1 ionotropic effect → increases heart contractility → increases cardiac output

Indications are cardiogenic shock , Reversible heart failure

Digoxin MOA: Digoxin has two principal mechanisms of action which are selectively employed depending on the indication: Positive Ionotropic: It increases the force of contraction of the heart by reversibly inhibiting the activity of the myocardial Na-K ATPase pump, an enzyme that controls the movement of ions into the heart.

Indications are Atrial fibrillation ,atrial flutter,

Heart failure,Abortion

3.What is the pathogenesis of renal involvement due to heart failure (cardio renal syndrome)? Which type of cardio renal syndrome is this patient?

Ans: Pathogenesis of cardiorenal syndrome is described below in the picture:

Stage 3 cardio renal syndrome is seen in this patient

4. What are the risk factors for atherosclerosis in this patient?

Ans: Hypertension is the risk factor for atherosclerosis in this patient.

5. Why was the patient asked to get those APTT, INR tests for review?

And: Because of Thrombosis and to check on development of thrombosis, this patient is asked to get APTT,INR tests for review.

GASTROENTEROLOGY

CASE 4A

A: *antomical location of etiology is pancreas(ductal obstruction,acinar cell injury,defective intracellular transport)

*The pathophysiology of acute pancreatitis is characterized by a loss of intracellular and extracellular compartmentation, by an obstruction of pancreatic secretory transport and by an activation of pancreatic enzymes Attributed to alcohol

2) What is the efficacy of drugs used along with other non pharmacological treatment modalities and how would you approach this patient as a treating physician?

PHARMACOLOGICAL INTERVENTIONS

1) ING. MEROPENAM

mechanism:Meropenem is bactericidal except against Listeria monocytogenes, where it is bacteriostatic. It inhibits bacterial cell wall synthesis like other β-lactam antibiotics. In contrast to other beta-lactams, it is highly resistant to degradation by β-lactamases or cephalosporinases.

2) ING. METROGYL

mechanism:Metronidazole diffuses into the organism, inhibits protein synthesis by interacting with DNA and causing a loss of helical DNA structure and strand breakage. Therefore, it causes cell death in susceptible organisms.

3) ING. AMIKACIN

mechanism:he primary mechanism of action of amikacin is the same as that for all aminoglycosides. It binds to bacterial 30S ribosomal subunits and interferes with mRNA binding and tRNA acceptor sites, interfering with bacterial growth.

4) TPN ( Total Parenteral Nutrition )

mechanism: the early administration of enteral nutrition must be the standard therapeutic approach in patients with severe acute pancreatitis it decreases the risk of infection; TPN is only required in a few patients.

5) IV NS / RL

mechanism:Patients with acute pancreatitis lose a large amount of fluids to third spacing into the retroperitoneum and intra-abdominal areas. Accordingly, they require prompt intravenous (IV) hydration within the first 24 hours. Especially in the early phase of the illness, aggressive fluid resuscitation is critically important.

6) ING. OCTREOTIDE

mechanism:

Like somatostatin, octreotide also decreases the release of growth stimulating hormones, decreases blood flow to the digestive organs, and inhibits the release of digestive hormones such as serotonin, gastrin, vasoactive intestinal peptide, secretin, motilin, and pancreatic polypeptide.

Octreotide is useful in overdose management of sulfonylurea type hypoglycemic medications, when recurrent or refractory to parenteral dextrose. Mechanism of action is the suppression of insulin secretion.

7) ING. PANTOP

mechanism:The mechanism of action of pantoprazole is to inhibit the final step in gastric acid production. In the gastric parietal cell of the stomach, pantoprazole covalently binds to the H+/K+ ATP pump to inhibit gastric acid and basal acid secretion. The covalent binding prevents acid secretion for up to 24 hours and longer.

8) ING. THIAMINE

mechanism:Vitamin B1 (thiamin) is indispensable for normal function/health of pancreatic cells due to its critical role in oxidative energy metabolism, ATP production, and in maintaining normal cellular redox state.

9) ING. TRAMADOL

mechanism:Tramadol is a centrally acting analgesic with a multimode of action. It acts on serotonergic and noradrenergic nociception, while its metabolite O-desmethyltramadol acts on the µ-opioid receptor. Its analgesic potency is claimed to be about one tenth that of morphine.

CASE 4B

1) What is causing the patient's dyspnea? How is it related to pancreatitis

1ans:the cause of dyspnea might be PLEURAL EFFUSION

2) Name possible reasons why the patient has developed a state of hyperglycemia

2 ans:

*This hyperglycemia could thus be the result of a hyperglucagonemia secondary to stress

* the result of decreased synthesis and release of insulin secondary to the damage of pancreatic β-cells

* elevated levels of catecholamines and cortisol

3) What is the reason for his elevated LFTs? Is there a specific marker for Alcoholic Fatty Liver disease?

A: LFT are increased due to hepatocyte injury

*If the liver is damaged or not functioning properly, ALT can be released into the blood. This causes ALT levels to increase. A higher than normal result on this test can be a sign of liver damage.

*elevated alanine transaminase (ALT) and aspartate transaminase (AST), usually one to four times the upper limits of normal in alcoholic fatty liver.

The reasons for a classical 2:1 excess of serum AST activity compared to serum ALT activity in alcoholic hepatitis have been attributed to

(i) decreased ALT activity most likely due to B6 depletion in the livers of alcoholics

(ii) mitochondrial damage leading to increased release of mAST in serum.

4) What is the line of treatment in this patient?

For the master chart to the "pancreatitis thesis project" please get in touch with Dr Shashikala PGY1 and Dr Divya PGY2 and share their insights into the above project problem they are working on.

A: Plan of action and Treatment:

Investigations:

✓ 24 hour urinary protein

✓ Fasting and Post prandial Blood glucose

✓ HbA1c

✓ USG guided pleural tapping

Treatment:

• IVF: 125 mL/hr

• Inj PAN 40mg i.v OD

• Inj ZOFER 4mg i.v sos

• Inj Tramadol 1 amp in 100 mL NS, i.v sos

• Tab Dolo 650mg sos

• GRBS charting 6th hourly

• BP charting 8th hourly

CASE 4C

1) What is the most probable diagnosis in this patient?

àDifferential Diagnosis:

· Ruptured Liver Abscess.

· Organized collection secondary to Hollow viscous Perforation.

· Organized Intraperitoneal Hematoma.

· Free fluid with internal echoes in Bilateral in the Subdiaphragmatic space.

· Grade 3 RPD of right Kidney

àThe most probably diagnosis is there is abdominal hemorrhage. This will give reasoning to the abdominal distention, and the blood which is aspirated.

2) What was the cause of her death?

àAfter leaving the hospital, the patient went to Hyderabad and underwent an emergency laparotomy surgery. The patient passed away the next day. Cause of her death can be due to complications of laparotomy surgery such as, hemorrhage (bleeding), infection, or damage to internal organs.

3) Does her NSAID abuse have something to do with her condition? How?

àNSAID-induced renal dysfunction has a wide spectrum of negative effects, including decreased glomerular perfusion, decreased glomerular filtration rate, and acute renal failure. Chronic NSAIDs use has also been related to hepatotoxicity. While the major adverse effects of NSAIDs such as gastrointestinal mucosa injury are well known, NSAIDs have also been associated with hepatic side effects ranging from asymptomatic elevations in serum aminotransferase levels and hepatitis with jaundice to fulminant liver failure and death

NEPHROLOGY

CASE 5A

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

CASE 5B

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 DISEASE (HIV,GASTROENTEROLOGY, PULMONOLOGY)

CASE 6

1.Which clinical history and physical findings are characteristic of tracheo esophageal fistula

1 ans:clinical history and physical finding in this paient that suggest tracheoesophageal fistula is that ,Cough occurs on taking food and liquids

(which was initially non productive then associated with sputum which is white in color , moderate in quantity and non foul smelling)

2) What are the chances of this patient developing immune reconstitution inflammatory syndrome? Can we prevent

2 ans: Immune reconstitution inflammatory syndrome (IRIS) occurs in two forms:

"unmasking" IRIS refers to the flare-up of an underlying, previously undiagnosed infection soon after antiretroviral therapy (ART) is started;

"paradoxical" IRIS refers to the worsening of a previously treated infection after ART is started.

*Patients with mycobacterial disease at the time of initiation of ART are at higher risk of developing IRIS with an approximate risk of 15%. Patients originating from endemic areas for tuberculosis and cryptococcal disease are at higher risk of developing IRIS.

How can immune reconstitution inflammatory syndrome be prevented?

*The most effective prevention of IRIS would involve initiation of ART before the development of advanced immunosuppression. IRIS is uncommon in individuals who initiate antiretroviral treatment with a CD4+ T-cell count greater than 100 cells/uL.

*Aggressive efforts should be made to detect asymptomatic mycobacterial or cryptococcal disease prior to the initiation of ART, especially in areas endemic for these pathogens and with CD4 T-cell counts less than 100 cells/uL.

*Two prospective randomized studies are evaluating prednisone and meloxicam for the prevention of paradoxical TB IRIS.

INFECTIOUS DISEASE AND HEPATOLOGY

CASE 7A

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

CASE 7B

1) Cause of liver abcess in this patient ?

1ans:cause of liver abcess in this patient is ENTAMOEBA HISTOLYTICA

2) How do you approach this patient ?

2 ans:APPROACH IN THE PATIENT OF AMOEBIC LIVER ABCESS

3) Why do we treat here ; both amoebic and pyogenic liver abcess

3ans:we treat the paient for both amoebic and pyogenic abcess so that we dont rely only on anti-amebic therapy and insure comple treatment of the cause

4) Is there a way to confirmthe definitive diagnosis in this patient?

4 ans: he confirmatory test for amoebic abcess is

*Serologic testing is the most widely used method of diagnosis for amebic liver abscess. In general, the test result should be positive, even in cases when the result of the stool test is negative (only extraintestinal disease).

*The diagnosis of amebic liver abscess was based on four or more of the following criteria:

(i) a space-occupying lesion in the liver diagnosed by ultrasonography and suggestive of abscess,

(ii) clinical symptoms (fever, pain in the right hypochondrium (often referred to the epigastrium), lower chest, back, or tip of the right shoulder),

(iii) enlarged and/or tender liver, usually without jaundice,

(iv) raised right dome of the diaphragm on chest radiograph, and

(v) improvement after treatment with antiamebic drugs (e.g., metronidazole).

INFECTIONS DISEASE

(ophthalmology,otorhinolaryngology,mucormycosis)

CASE 8A

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. 3 years ago- diagnosed with hypertension

2. 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

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 that occurs in people with uncontrolled diabetes

(https://www.cdc.gov/fungal/diseases/mucormycosis/definition.html ) the fungus enters the sinuses from the environment and then the brain.

The patient was also diagnosed with acute infarct in the left frontal and temporal lobe. Mucormycosis is associated with the occurrence of CVA ( https://journal.chestnet.org/article/S0012-3692(19)33482-8/fulltext#:~:text=There%20are%20few%20incidences%20reported,to%20better%20morbidity%2Fmortality%20outcomes. )

2:QUESTION: What is the efficacy of drugs used along with other non-pharmacological treatment modalities and how would you approach this patient as a treating physician?

The proposed management of the patient was –

1. inj. Liposomal amphotericin B according to creatinine clearance

2. 200mg Iitraconazole was given as it was the only available drug which was adjusted to his creatinine clearance

3. Deoxycholate was the required drug which was unavailable

https://pubmed.ncbi.nlm.nih.gov/23729001/ this article talks about the efficacy and toxicity of different formulations of amphotericin B

along with the above mentioned treatment for the patient managing others symptoms is also done by-

I. Management of diabetic ketoacidosis –

(a) Fluid replacement- The fluids will replace those lost through excessive urination, as well as help dilute the excess sugar in blood.

(b) Electrolyte replacement-The absence of insulin can lower the level of several electrolytes in blood. Patient will receive electrolytes through a vein to help keep the heart, muscles and nerve cells functioning normally.

(c) Insulin therapy- Insulin reverses the processes that cause diabetic ketoacidosis. In addition to fluids and electrolytes, patient will receive insulin therapy

QUESTION: What are the postulated reasons for a sudden apparent rise in the incidence of mucormycosis in India at this point of time?

Mucormycosis is may be being triggered by the use of steroids, a life-saving treatment for severe and critically ill Covid-19 patients. Steroids reduce inflammation in the lungs for Covid-19 and appear to help stop some of the damage that can happen when the body's immune system goes into overdrive to fight off coronavirus. But they also reduce immunity and push up blood sugar levels in both diabetics and non-diabetic Covid-19 patients.

With the COVID-19 cases rising in India the rate of occurrence of mucormycosis in these patients is increasing

INFECTIONS DISEASE( covid cases)

https://in.docworkspace.com/d/sIJ-88MRW2ejShQY

Case 1

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.

CASE 2

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 host

s 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 3

1. Why was this patient given noradrenaline?

noradrenaline, is a medication used to treat people with very low blood pressure. Noradrenaline is a vasoconstrictor that predominantly stimulates α1 receptors to cause peripheral vasoconstriction and increase blood pressure.

It also has some β1 receptor agonist activity that results in a positive inotropic effect on the heart at higher doses.1,2

2. What is the reason behind testing for LDH levels in this patient?

LDH is an intracellular enzyme found in cells in almost all organ systems, which catalyzes the interconversion of pyruvate and lactate, with concomitant interconversion of NADH and NAD+

Lactate dehydrogenase (LDH) is one such biomarker of interest, especially since elevated LDH levels have been associated with worse outcomes in patients with other viral infections in the past

there was a >6-fold increase in odds of severe disease and a >16-fold increase in odds of mortality in patients with elevated LDH.

3. What is the reason for switching from BiPAP to mechanical ventilation with intubation in this patient? What advantages did it provide?

BiPap may not be a good option if your breathing is very poor. It may also not be right for you if you have reduced consciousness or problems swallowing

Therefore patient might have got shifted to Mechanical ventilation

Advantages of Mechanical ventilation

The patient does not have to work as hard to breathe – their respiratory muscles rest.

The patient's as allowed time to recover in hopes that breathing becomes normal again.

Helps the patient get adequate oxygen and clears carbon dioxide.

Preserves a stable airway and preventing injury from aspiration.

CASE 4

1. Is the elevated esr due to covid related inflammation?

Erythrocyte sedimentation rate (ESR) is a blood test. It measures how quickly erythrocytes, or red blood cells, separate from a blood sample that has been treated so the blood will not clot.

The sustained high level of ESR possibly brings a negative effect on COVID-19 patients' prognosis

However the elevation in esr cannot be explained based on the present knowledge on Covid

2. What was the reason for this patient's admission with mild covid? What are the challenges in home isolation and harms of hospitalization?

after 14 days of isolation he got tested again for COVID-19 which was positive . He then developed fever since 4 days, cough which was productive since 4 days and shortness of breath grade 3 since 2 days. He also had fatigue.He lost the sense of taste and smell.

Since the patient has SOB of grade 3. This poses a challenge for home isolation.

Patients with COVID-19 had almost 19 times the risk for acute respiratory distress syndrome (ARDS) than did patients with influenza, (adjusted risk ratio [aRR] = 18.60; 95% confidence interval [CI] = 12.40–28.00), and more than twice the risk for myocarditis (2.56; 1.17–5.59), deep vein thrombosis (2.81; 2.04–3.87), pulmonary embolism (2.10; 1.53–2.89), intracranial hemorrhage (2.85; 1.35–6.03), acute hepatitis/liver failure (3.13; 1.92–5.10), bacteremia (2.46; 1.91–3.18), and pressure ulcers (2.65; 2.14–3.27). The risks for exacerbations of asthma (0.27; 0.16–0.44) and chronic obstructive pulmonary disease (COPD) (0.37; 0.32–0.42) were lower among patients with COVID-19 than among those with influenza. The percentage of COVID-19 patients who died while hospitalized (21.0%) was more than five times that of influenza patients (3.8%), and the duration of hospitalization was almost three times longer for COVID-19 patients.

CASE 5

1) What was the reason for coma in this patient?

The patient has an spo2 of 20%. This might have lead to cerebral hypoxia thus leading to coma.

Also, low blood potassium can make you short of breath, as it can cause the heart to beat abnormally. This means less blood is pumped from your heart to the rest of your body

Thus low spo2 and thus coma

2) What were the competency gaps in hospital 1 Team to manage this intubated comatose patient that he had to be sent to hospital 2? Why and how did hospital 2 make a diagnosis of hypokalemic periodic paralysis? Was the coma related?

Hospital 1 might not have correlated Severe weakness of 4 limbs with low values of potassium which hospital 2 has diagnosed.

Yes, coma is related to Hypokalemia periodic paralysis as it might have caused cerebral hypoxia.

3) How may covid 19 cause coma?

After cessation of sedatives, the described cases all showed a prolonged comatose state.

unconsciousness after prolonged periods of mechanical ventilation in the ICU

CASE 6

1. What was the cause of his altered sensorium?

Can be any of the following reasons

An altered state is any mental state(s), induced by various physiological( increased hospital stay) , psychological( mental depression due to isolation), or pharmacological maneuvers or agents( drugs of COVID)

2. What was the cause of death in this patient?

This patient is an elderly chronic alcoholic and smoker.

This might have delayed his healing process thus causing death

Also he had elevation LFT and RFT values

Case 8

1. Can psoriasis be a risk factor for severe form of COVID?

Elderly psoriasis patients and/or patients using conventional immunosuppressive regimens and biologic agents are at higher risk for infectious diseases.

But the frequency of COVID-19 does not increase in patients using immunosuppressants, including those receiving biological therapy with a diagnosis of psoriasis

2. Can the increased use of immunomodulatory therapies cause further complications in the survivors?

According to the present knowledge on Covid,there is no indication that people taking immunomodulatory drugs for other diagnosed conditions should be concerned that their medication increases their risk for severe COVID-19,"

3. Is mechanical ventilation a risk factor for worsened fibroproliferative response in COVID survivors?

patients of Covid with greater fibrotic changes required more prolonged mechanical ventilation, and this in turn was associated with an increased severity of systemic organ failure.

Hence Mechanical ventilation is risk factor

CASE 9

•What is the type of DM the patient has developed ?(is it the incidental finding of type 2 DM or virus induced type 1DM )?

It is most probably the type -1 diabetes ,developed due to viral infection and cytokine storm induced damage to pancreas might have caused the diabetes .!so it could be virus induced type -1 DM

•Could it be steroid induced Diabetes in this patient?

There is a chance for steroid induced diabetes too but it doesn’t seem much significant when compared to virus induced diabetes .

CASE 10

What are the known factors driving early recovery in covid?

These might be the factors responsible for early recovery of Covid:

1. Better immune response of the patient

2. Good food habits prior to And during the Covid period

3. Early detection of symptoms and thus using medication

4. Age related (Elderly have a slow recovery than young)

5. Maintaining hygiene even after Covid infection

6. Mental strength

7. Health related (patient with Comorbidities have slow recovery)

CASE 11

1) How is the diabetes related to the prognosis of COVID patients? What are the factors precipitating diabetes in a patient developing both covid as well as Diabetes for the first time?

Ans: DM increases the complications of COVID-19 and the risk of COVID-19 related mortality Current evidence demonstrates that patients with DM are more likely to experience severe symptoms and complications than patients without DM due to COVID-19 . One hypothesis is that hyperglycemia facilitates the virus entry into the cells since ACE2 and virus both need glucose for their function

DM is associated with chronic low-grade inflammation in the body, and patients with diabetes have higher circulatory levels of cytokines . Also, these cytokines are intimately involved in the pathophysiology of various diabetic complications and increase the risk of diabetes-induced tissue damages .

COVID-19 is a viral infection characterized by storms of inflammatory responses and higher levels of circulatory cytokines . These storms are frequent in patients with severe stages of COVID-19 [42]. Clinical evidence demonstrates that COVID-19 patients have impaired immune system activity, especially with critical illness . Many of the COVID-19 victims appear to be harmed more by their immune system hyperactivity. Therefore, lowering the inflammatory response is a potential strategy for the management of COVID-19 . Due to the presence of chronic inflammation in DM, it could be a potentiator of inflammatory responses and increase the likelihood of inflammation storms in COVID-19 patients. Patients with diabetes associated with COVID-19 potentially have a higher rate of inflammatory responses

inflammatory cytokines including IL-6, CRP, serum ferritin, coagulation index, and D-dimer were significantly higher than nondiabetic COVID-19 patients. This finding suggests that patients with DM are more susceptible to inflammatory storms leading to more severe degrees of the respiratory infections . Also, previous studies on coronaviruses demonstrated that inflammatory milieu increases the likelihood of infection with coronaviruses . It has been shown that host cell condition has significant effects on the infectivity and pathogenesis of various pathogens such as SARS-CoV-2 . Thus, having low-grade chronic inflammation is commonly seen in patients with diabetes increase the likelihood of inflammatory storms resulting in more severe tissue damage . Therefore, inflammation could be a possible link between DM and COVID-19 progression .

DM induces oxidative stress via at least ten molecular mechanisms such as mitochondrial dysfunction, weakening the cellular antioxidant elements, glucose autoxidation, glycation and related pathways, lipids peroxidation, activation of free radical generator enzymes, polyol (sorbitol) pathway, protein kinase C isoforms, hexosamine pathway, and redox state changes [. This oxidative milieu is implicated in most viral infections and may increase the pathogenicity of viruses such as coronaviruses . Since SARS-CoV-2 exploits the host cell machinery for their replication and spread, the environment of the host cells is a crucial determinant for the infectivity of invader pathogens, and oxidative milieu is one of the main factors facilitating coronavirus replication in the host cells

COVID-19 induces tissue injuries in the diabetic milieu is at least partly associated with glucotoxicity which can onset and promote other pathophysiologic mechanisms . In a recent study, Codo and coworkers reported that elevated levels of glucose favor COVID-19 infections via a hypoxia-inducible factor-1α- (HIF-1α-) dependent mechanism [74]. They suggested that patients with diabetes are more prone to SARS-CoV2 due to toxic effects of hyperglycemia . Also, we suggest that higher severity of tissue injuries in the respiratory system which occurs in patients with DM infected with SARS-CoV2 are closely related to the toxic effects of hyperglycemia that induces various injurious pathways that damage the infected host cells.

ER stress is a common event in the diabetic,

The ER stress increases the infectivity of coronaviruses and raises the pathogenicity of these viruses . The cells overexpressing S2 subunit of SARS-CoV spike also upregulate the GRP94 and GRP78 chaperones [83, 84]. Also, other biomarkers of ER stress such as HERPUD1 (homocysteine-inducible, ER stress-inducible, ubiquitin-like domain member 1) were upregulated in murine cells infected with SARS-CoV , indicating that ER stress has a crucial role in the pathogenicity of the coronaviruses .

SARS-CoV2, which is responsible for the recent pandemic of COVID-19, has close interactions with RAAS activity . SARS-CoV2 enters the cells via binding with spike (S) protein of ACE2 receptors, and hence, pharmacologic agents modulating RAAS activities have been proposed for the management of COVID-19 pandemic in recent studies

On the other hand, patients with DM have some degree of changes in RAAS functions and widely use ACE inhibitors or ARBs (Angiotensin receptor blockers) to prevent or treat diabetes-induced vascular disorders . Also, these drugs repeatedly showed beneficial effects against pulmonary complications and the risk of pulmonary infection in hypertensive patients with altered RAAS function compared to normotensive individuals . Thus, it could be hypothesized that patients with DM are more likely prone to more severe degrees of COVID-19 at least partly due to their altered RAAS functions.

DM is a potent upstream event for apoptosis, and diabetic milieu is commonly associated with higher levels of apoptosis dependent cellular death. Hence, it may be other possible explanation for the finding that patients with DM infected with SARS-CoV2 experience more severe tissue injuries and cellular death compared to patients without DM.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes Covid-19, binds to angiotensin-converting enzyme 2 (ACE2) receptors, which are expressed in key metabolic organs and tissues, including pancreatic beta cells, adipose tissue, the small intestine, and the kidneys.Thus, it is plausible that SARS-CoV-2 may cause pleiotropic alterations of glucose metabolism that could complicate the pathophysiology of preexisting diabetes or lead to new mechanisms of disease.

2) Why couldn't the treating team start her on oral hypoglycemics earlier?

Ans: She is on insulin injections I think to control it

I think first to control the high range diabetes they have give her insulin injections I think oral hypoglycaemic drugs has some wht slower results than if

CASE 12

1) What are the potential bioclinical markers in this patient that may have predicted the prolonged course of her illness?

The potential biochemical markers in this patient are

Elevated levels of

LFT- Total bilirubin : 1.24 mg/dl

Direct bilirubin : 0.67 mg/dl

SGOT : 73 units/ lit

SGPT : 80 units/ lit

ALP : 342 units/ lit

RFT Blood urea : 34 mg/dl

Sodium : 150 meq/lit

Potassium : 5.2 meq/lit

SERUM LDH 571 units/lit

FBS 332 mg /dl

Case 13

1. What are the consequences of uncontrolled hyperglycemia in covid patients?

Ans: Adults with diabetes or uncontrolled hyperglycemia hospitalized with COVID-19 experienced a longer length of stay and markedly higher mortality compared with adults without diabetes or uncontrolled hyperglycemia, according to findings published in the Journal of Diabetes Science and Technology.

2.Does the significant rise in LDH suggests multiple organ failure?

Ans: Yes the significant rise in LDH levels can lead to multiple organ failure due to tissue injury.

Lactate dehydrogenase (LDH) is an enzyme required during the process of turning sugar into energy for your cells. LDH is present in many kinds of organs and tissues throughout the body, including the liver, heart, pancreas, kidneys, skeletal muscles, lymph tissue, and blood cells.

When illness or injury damages your cells, LDH may be released into the bloodstream, causing the level of LDH in your blood to rise. High levels of LDH in the blood point to acute or chronic cell damage, but additional tests are necessary to discover its cause. Abnormally low LDH levels only rarely occur and usually aren’t considered harmful.

Because LDH is present in so many types of cells, high levels of LDH may indicate a number of conditions. Elevated levels of LDH can include:

blood flow deficiency

cerebrovascular accident, also known as a stroke

certain cancers

heart attack

hemolytic anemia

infectious mononucleosis

liver disease, such as hepatitis

muscle injury

muscular dystrophy

pancreatitis

tissue death

use of alcohol or certain drugs

sepsis and septic shock

CASE 14

1)Which subtype of ICU psychosis did the patient land into according to his symptoms?

The subtype of icu psychosis in this patient is of HYPERACTIVE

It is characterized by agitation, restlessness, emotional lability, and positive psychotic features such as hallucinations, illusions that often interfere with the delivery of care. It should be remembered that new-onset psychotic symptoms in older adult patients are unlikely to be a primary mental illness, and search for a pharmacological or physiological cause should be carried out.

2)What are the risk factors in the patient that has driven this case more towards ICU pyschosis?

There are more chances for a Covid patient to be landing into ICU psychosis if he has any of these Major complications being 1) cardiovascular diseases 2) hypertension and 3) cerebrovascular diseases

Since this patient is a known case of htn since 2 years and had a cerebrovascular episode 2 years back

3)The patient is sleep deprived during his hospital stay..Which do u think might be the most propable condition?

A) Sleep deprivation causing ICU pyschosis

B) ICU psychosis causing sleep deprivation

The most probable condition in this case might be SLEEP DEPRIVATION CAUSING ICU PSYCHOSIS

these might be have caused sleep disturbance and thus lead to icu pyschosis:

Environmental contributors include patient care, noise, light, and medications.

Patient factors, including illness severity, SOB can also play important roles

4) What are the drivers toward current persistent hypoxia and long covid in this patient?

The pneumonia that COVID-19 causes tends to take hold in both lungs. Air sacs in the lungs fill with fluid, limiting their ability to take in oxygen and causing shortness of breath, cough and other symptoms.

While most people recover from pneumonia without any lasting lung damage, the pneumonia associated with COVID-19 can be severe. Even after the disease has passed, lung injury may result in breathing difficulties that might take months to improve.

This might be the cause for persistent hypoxia in this patient

CASE 15

1. As the patient is a non- diabetic, can the use of steroids cause transient rise in blood glucose?

Yes, Increase in the blood glucose might be due to the use of steroids, in this case Dexamethasone

2. If yes, can this transient rise lead to long term complication of New-onset diabetes mellitus?

High blood glucose levels whilst taking steroids may subside after one stop taking steroids, however, some people may develop type 2 diabetes which will need to be managed for life.

Type 2 diabetes is more likely to develop following longer term usage of steroids, such as usage of oral corticosteroids for longer than 3 months.

3. How can this adversely affect the prognosis of the patient?

The reason for worse prognosis in people with diabetes is likely to be multifactorial, thus reflecting the syndromic nature of diabetes. Age, sex, ethnicity, comorbidities such as hypertension and cardiovascular disease, obesity, and a pro-inflammatory and pro-coagulative state all probably contribute to the risk of worse outcomes

4. How can this transient hyperglycemia be treated to avoid complications and bad prognosis?

At admission: pre-meal BG: 150 to 180 mg/dl and/or post-meal BG 200 to 250 mg/dl)

If there is an anticipated delay in consulting endocrinologist/physician, initiate on Tab Metformin (either immediate or sustained release) 500 mg BD and a Gliptin (Tab Vildagliptin 50 mg BD or Tab Sitagliptin 100 mg OD or Tab Linagliptin 5 mg OD or Tab Teneligliptin 20 mg OD)

Indication: At admission: pre-meal BG: ≥180 mg/dl or post-meal BG ≥250 mg/dl

A. Total daily dose (TDD) = 0.4 units/kg/day (age > 65 yr, nephropathy or liver disease, use 0.2 units/kg/day)

B. Total daily dose is divided equally into 4 doses (25% each): 3 doses are for bolus insulin (Regular insulin 30 min before breakfast, before lunch and before dinner) and 1 dose for basal insulin (Inj. NPH insulin at bed time/ 2 hours after dinner)

If pre-meal BG value is 140 to 180 mg/dl and/or post-meal BG value is 180 to 250 mg/dl → consult endocrinologist/physician for OAD optimization

B. If pre-meal BG value ≥180 mg/dl and/or post-meal BG value ≥250 mg/dl despite being on OAD → start basal-bolus insulin regimen using calculation mentioned in section 3A (Kindly note that in this particular scenario, OADs apart from Metformin and Gliptins need to be stopped).

5. What is thrombophlebitis fever?

Thrombophlebitis is when a blood clot Any veins and slows the blood flow in the vein. It may be due prolonged use of IV cannula.

This causes fever

6. Should the infusion be stopped inorder to control the infusion thrombophlebitis? What are the alternatives?

There is no need to stop infusion to control Theombophlebitis. Instead change the IV cannula to opposite or another site. If there is pain at that site use aspirin or ibuprofen

Case 17

Does hypertension have any effect to do with the severity of the covid infection.If it is, Then how?

Ans: Severity of COVID-19 illness is skewed towards the elderly population who have a higher prevalence of hypertension.

SARS-CoV-2 and Interaction with the Renin-Angiotensin Aldosterone System

ACE2 is a modulator of the RAAS, a critical neurohormonal pathway that regulates blood pressure and fluid balance.12 The end product of the RAAS, angiotensin II, is a key vasoactive hormone that binds to angiotensin II receptor type 1 (AT1) located in the heart, lungs, blood vessels, kidneys, and adrenal glands, and it plays a central role in myocardial hypertrophy and fibrosis, inflammation, vascular remodeling, and atherosclerosis.13 ACE2 is expressed in many human tissues including the nasal epithelium, heart, kidneys, and lungs, and inactivates angiotensin II diminishing its vasoconstrictive and myoproliferative effects.14

SARS-CoV-2 binds to the ACE2 receptor via its spike (S) protein to allow entry into host cells. This complex is endocytosed leading to down-regulation of ACE2 and resulting in local accumulation of angiotensin II. Severe respiratory illness is a hallmark of COVID-19 and a primary cause of morbidity- and mortality-local activation of the RAAS is proposed as a mechanism for severe lung injury.

2.what is the cause for pleural effusion to occur?

Ans: Pleural effusion is an uncommon finding in coronavirus infection.

Until this time, there is no clear evidence of how the virus can cause pleural effusion, but it carry an adverse prognostic sign that may indicate a bacterial super-infection in COVID-19 pneumonia.

About 20% of pleural effusions are of unknown aetiology despite fluid analysis, hence the requirement for more invasive diagnostic procedures like pleural biopsy under thoracoscopy guide.The prevalence of pleural effusion is 5–10%

Pleural effusion may present as a complication in patients with coronavirus disease; however, there is still scanty of data to support such a claim. More cases to be identified and studied to prove or refute this theory.

CASE 18

Question 1:

What is the reason for hypoalbuminemia in the patient?

Answer:

It may be due to pulmonary capillary leakage in lungs , in response to epithelial endothelial damage due to covid infection.

https://pubmed.ncbi.nlm.nih.gov/33411411/2.

Question 2:

What could be the reason for exanthem on arms? Could it be due to covid-19 infection ?

Answer:

Yes, what the patient is experiencing is known as viral exanthem which is one of the cutaneous manifestation of COVID-19.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7549735/

Question 3:

What is the reason for Cardiomegaly?

Answer:

The most probable cause of that appearance is AP view of the chest. When an anteroposterior view is taken, most times the CXR shows false cardiomegaly. To confirm the cardiomegaly a PA view of chest must be taken.

Another possible cause can be Direct Myocardial Cell Injury. The interaction of SARS-CoV-2 with ACE2 can cause changes to the ACE2 pathways, leading to acute injury of the lung, heart, and endothelial cells. A small number of case reports have indicated that SARS-CoV2 might directly infect the myocardium, causing viral myocarditis. However, in most cases, myocardial damage appeared to be caused by increased cardiometabolic demand associated with the systemic infection and ongoing hypoxia caused by severe pneumonia or ARDS

https://www.ncbi.nlm.nih.gov/books/NBK556152/

Question 4:

What other differential diagnoses could be drawn if the patient tested negative for covid infection?

Answer:

Possible alternative diagnoses may include:

• Influenza

• Mycoplasma pneumonia

• Parainfluenza

• Respiratory syncytial virus

• Streptococcus pneumonia

• Other viral or bacterial pneumonia.

Question 5:

Why is there elevated D-Dimer in covid infection? What other conditions show D-dimer elevation?

Answer:

It is well known that D-dimer are produced during fibrin breakdown and serve as a marker of fibrinolytic activity. A relationship between proinflammatory cytokines and markers of activation of the coagulation cascade, including D-dimer, has been demonstrated in critical patients or patients with sepsis .There is also evidence that under inflammatory conditions, the alveolar haemostatic balance is shifted towards a predominance of prothrombotic activity .In addition, pro-inflammatory cytokines may be involved in endothelial injury, and may activate coagulation and inhibit fibrinolysis in patients with severe sepsis.

• D-dimer can be elevated such as in pregnancy, inflammation, malignancy, trauma, liver disease (decreased clearance), heart disease, sepsis or as a result of hemodialysis, CPR or recent surgery)

Case 20

1. Can usage of steroids in diabetic Covid patients increases death rate because of the adverse effects of steroids?

Ans: findings from both observational studies and RCTs confirm a beneficial effect of corticosteroids on short-term mortality and a reduction in need for mechanical ventilation. And although data in the studies were too sparse to draw any firm conclusions, there might be a signal of delayed viral clearance and an increase in secondary infections.

2.Why many COVID patients are dying because of stroke though blood thinners are given prophylactically???

Ans: The results that are in so far suggest that individuals hospitalized, but not severely ill, with COVID-19 who received a full intravenous dose of the common blood thinner heparin were less likely to need vital organ support, including mechanical ventilation, compared to those who received the lower “prophylactic” subcutaneous dose. It’s important to note that these findings are in contrast to results announced last month indicating that routine use of a full dose of blood thinner for patients already critically ill and in the ICU wasn’t beneficial and may even have been harmful in some cases.

2.Does chronic alcoholism have effect on the out come of Covid infection????

If yes,how??

Ans:Though there’s still limited data on the link between alcohol and COVID-19, past evidence shows alcohol consumption can worsen the outcomes from other respiratory illnesses by damaging the lungs and gut, and impairing the cells responsible for immune function.

When someone is exposed to a virus, the body mounts an immune response to attack and kill the foreign pathogen.

In general, the healthier a person’s immune system is, the quicker it can clear out a virus and recover from a disease like COVID-19.

By default, alcohol makes it harder for the immune system to gear up and defend the body against harmful germs.

“Alcohol has diverse adverse effects throughout the body, including on all cells of the immune system, that lead to increased risk of serious infections,”

In the lungs, for example, alcohol damages the immune cells and fine hairs that have the important job of clearing pathogens out of our airway.

If the cells lining a person’s airway are damaged from alcohol, then viral particles, such as COVID-19, more easily gain access, causing immune cells, which fight off infection, to not work as well, leading to increased overall risks of more severe diseases as well as complications,”

10th Question

Personal experience:

I was thrilled to be a part of this learning experience where in I could personally place myself in the place of a doctor and learn how to take a case properly. I keep learning new things through the blogs. This helps me a lot with integrating my knowledge practically. This real life experience shows us the hurdles in taking a case through phone. Nevertheless we always have a lot to learn. Thank you for this opportunity.

39 Nagarjuna

General medicine Assignment

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