9th case medicine blended assignment
I have been given the following cases to solve in an attmept to understand the topic of 'Patient clinical data analysis' to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and diagnosis and coem up with a treatment plan.
Case1
Covid pneumonia in a pre existing case of interstitial lung disease
Q1:How does the pre-existing ILD determine the prognosis of this patient?
Ans:COVID-19 pneumonia has a higher mortality in patients with preexisting ILD. COVID-19 should be considered in the diagnosis of patients with ILD who present with fever or worsening of their respiratory symptoms, and an early confirmation should be attempted. Avoidable visits to health-care facilities should be curtailed for stable patients with ILD, to reduce the risk of exposure to SARS-CoV-2. The use of immunosuppressive agents should be limited to the lowest effective dosing, according to best practice, while antifibrotics may be used without any change in approach.
Q2:Given the history of autoimmune disease in the patient, how does the administration of steroids for COVID affect her RA and hypothyroidism?
Ans:
Q3:Would this patient have an increased risk for post covid autoimmune response compared to patients without a history of autoimmune disease?
Ans : yes
Q4:Why was she prescribed clexane (enoxaparin)?
Ans:Patients with COVID-19 are at high risk of developing a venous thromboembolism (VTE) and it is essential that effective thromboprophylaxis with parenteral drugs (LMWH, UFH) is considered for all patients admitted to hospital especially in case of severe pneumonia.
CASE 2
A 50 year old female with Viral Pneumonia secondary to Covid-19
Q1: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?
Ans:
Beta cells in the pancreas contain a significant number of so-called ACE2 receptors. These receptors are believed to be where the spike protein from the coronavirus attaches to cells. Beta cells produce insulin, a hormone that helps usher the sugar from foods into the body's cells for fuel. The authors theorized that a coronavirus infection, which affects the ACE2 receptors, might also damage beta cells in the pancreas.This process is similar to what's believed to occur in type 1 diabetes. The immune system mistakenly turns on healthy cells (autoimmune attack) after a viral infection and damages or destroys beta cells, possibly causing type 1 diabetes.
Q2:Did the patient's diabetic condition influence the progression of her pneumonia?
Ans:รน
Yes, patients with diabetes are more susceptible to any inflammatory storm eventually leading ti rapid detoriation of covid19.
Q3:What is the role of D Dimer in the monitoring of covid? Does it change management or would be considered overtesting?
Ans:D-dimer is commonly elevated in patients with COVID-19. D-dimer levels correlate with disease severity and are a reliable prognostic marker for in-hospital mortality in patients admitted for COVID-19.
CASE 3:
A 26 Year Old Female with Fever and Shortness of Breath
Q1:Why was this patient given noradrenaline?
Ans:because the patient had AKI.
Q2:What is the reason behind testing for LDH levels in this patient?
Ans:A number of studies have observed a decrease in total cholesterol, LDL-C, and HDL-C levels in patients with COVID-19 infections. In most studies the decrease in LDL-C and/or HDL-C was more profound the greater the severity of the illness
Q3:What is the reason for switching from BiPAP to mechanical ventilation with intubation in this patient? What advantages did it provide?
Ans:The main benefits of mechanical ventilation are the following:
- 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.
CASE 4:
29 year old male patient with viral pneumonia secondary to COVID-19
Q1:Is the elevated esr due to covid related inflammation?
Ans: yes,coronavirus infection will lead to systemic inflammatory response and immune system
dysfunction, and various systems of human were likely to have different degrees’ damage. However, due to
individual differences in immune system, COVID-19 patients also have different progression or prognosis.
C-reactive protein as an inflammatory marker and a reliable prognostic factor, has a significant positive
effect on ESR, which can be used as a reference to predict the likelihood of encountering other diseases after recovery.
Q2:What was the reason for this patient's admission with mild covid? What are the challenges in home isolation and harms of hospitalization?
Ans: the reason for admission with mild covid could be due to shortness of breath.
Challenges in home isolation:
• the underlying challenge would be associated with families having small homes to isolate themselves away from other members of the family.Without proper management even mild symptoms could become dreadful.
CASE 5:
45 Y/O MALE WITH COVID-19 AND COMORBIDITIES (ALTERED SENSORIUM, AZOTEMIA, HYPOKALEMIA.)
Q1:What was the reason for coma in this patient?
Ans:
Q2: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?
Ans:
Q3:How may covid 19 cause coma?
Ans:
CASE:6
65 YEARS OLD MALE WITH VIRAL PNEUMONIA SECONDARY TO COVID-19.
Q1:What was the cause of his altered sensorium?
Ans:. In COVID-19, both central and peripheral nervous systems can be affected. The SARS-CoV-2 virus causes the disease COVID-19 and has the potential to invade the brain. The SARS-CoV-2 virus enters the brain either via a hematogenous route or olfactory system. Angiotensin-converting enzyme two receptors, present on endothelial cells of cerebral vessels, are a possible viral entry point. The most severe neurological manifestations, altered sensorium (agitation, delirium, and coma), are because of hypoxic and metabolic abnormalities.Icu psychosis
Q2:What was the cause of death in this patient?
ANS: it could be due to icu psychosis,multi organ failure.
CASE 7:
A 67 year old lady in the ICU with COVID induced Viral Pneumonia .
Q1:What is the grade of pneumonia in her?
Ans: it is 12/25 according to her ct scan.
Q2:What is the ideal day to start steroids in a patient with mild elevated serum markers for COVID ?
Ans:
Steroids should be initiated early in pulmonary phase to counter the immune dysregulation. Ideal time for steroid administration is after the 8th day of symptoms, when the virus is very low replecable and inflammatory response is about to settle down.
Q3:What all could be the factors that led to psychosis in her ?
Ans: high dose corticosteroid use has been identified as a significant associated factor in psychotic presentations.
Q4:What all are the other means to manage such a case of psychosis?
Ans:For patients with known psychotic illness, expert opinion recommends oral risperidone or olanzapine. The combination of oral risperidone plus lorazepam may be as effective as the IM haloperidol and IM lorazepam combination. Patients who are too agitated to take oral doses may require parenteral medications.
Q5: What all should the patient and their attendants be careful about ( w.r.t. COVID )after the patient is discharged ?
Ans:
The researchers have found in the study that people who recovered from coronavirus infection had a 40–60 per cent higher risk of re-admission within the next 10 days. People discharged from hospital after covid 19 appear to have increased rates of organ damage ("multiorgan dysfunction") compared with similar individuals in the general population.
Q6:What are the chances that this patient may go into long covid given that her "D Dimer" didn't come down during discharge?
Ans:yes, there are high chances that this patient might go into long covid.
CASE 8:
35YR/M WITH VIRAL PNEUMONIA SECONDARY TO COVID 19 INFECTION
Q1:Can psoriasis be a risk factor for severe form of COVID?
Ans:
As psoriasis is a chronic immune-mediated condition, some people may take immunosuppressant drugs to keep their symptoms under control.
These medications can reduce immune function, which may increase the risk of infection with SARS-CoV-2 or other infectious agents. Immunosuppressive drugs could also increase the risk of severe symptoms.
Q2:Can the increased use of immunomodulatory therapies cause further complications in the survivors?
Ans:
Yes, immunomodulatory therapies can cause further complications.
Q3:Is mechanical ventilation a risk factor for worsened fibroproliferative response in COVID survivors?
Ans:yes,Virus-induced lung injury, immune response, and attempts at healing are central to the process of fibrogenesis. Predictors of pulmonary fibrosis putatively include advanced age, illness severity, length of ICU stay and mechanical ventilation, smoking, and chronic alcoholism.
CASE9:
A 45 year old female with viral pneumonia secondary to Covid-19
Q1:What is the type of DM the patient has developed ?(is it the incidental finding of type 2 DM or virus induced type 1DM )?Ans: 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
Q2:Could it be steroid induced Diabetes in this patient?Ans:There is a chance for steroid induced diabetes too but it doesn’t seem much significant when compared to virus induced diabetes .
Case10:
A little difference that altered the entire covid recovery game: a report of two patients with focus on imaging findings
Q1:What are the known factors driving early recovery in covid?
Ans:
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)
CASE11:
Q1: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:People with diabetes with COVID-19 are at a greater risk of worse prognosis and mortality. Given the high worldwide prevalence of diabetes, these individuals represent a large vulnerable segment of the COVID-19 population. The poorer prognosis of people with diabetes is the likely consequence of the syndromic nature of the disease . hyperglycaemia, older age, comorbidities, and in particular hypertension, obesity, and cardiovascular disease all contribute to increase the risk in these individuals.
Q2:Why couldn't the treating team start her on oral hypoglycemics earlier?
Ans:oral hypoglycemics have short results.
Case 12
Q1:What are the potential bioclinical markers in this patient that may have predicted the prolonged course of her illness?
Ans: her serum ldh and crp are higher than normal levels. And her rft was also above normal levels .
CASE13:
58 years female patient with viral pneumonia secondary to covid-19
Q1:What are the consequences of uncontrolled hyperglycemia in covid patients?
Ans:
•Severe inflammatory changes in lungs in case of covid pneumonia.
•Delayed recovery of the patient .
Since elevated blood sugar levels favors the virus growth and multiplication.
Q2:Does the significant rise in LDH suggests multiple organ failure?
Ans:
High LDH levels
Extremely high levels of LDH could indicate severe disease or multiple organ failure. Because LDH is in so many tissues throughout the body, LDH levels alone won't be enough to determine the location and cause of tissue damage.
Q3:What is the cause of death in this case?
Ans:Cause of death could be most probably due to:
•Severe covid pneumonia associated with uncontrolled hyperglycaemia
•Multiple organ failure
Case14:
COVID with ICU psychosis
Q1:Which subtype of ICU psychosis did the patient land into according to his symptoms?
Ans: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.
Q2:What are the risk factors in the patient that has driven this case more towards ICU pyschosis?
Ans: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
Ans: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.
Q2:What are the risk factors in the patient that has driven this case more towards ICU pyschosis?
Ans: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
Q3:The patient is sleep deprived during his hospital stay..Which do u think might be the most propable condition?
Ans:
Q3:The patient is sleep deprived during his hospital stay..Which do u think might be the most propable condition?
Ans:
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
Q4:What are the drivers toward current persistent hypoxia and long covid in this patient?
Ans: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
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
Q4:What are the drivers toward current persistent hypoxia and long covid in this patient?
Ans: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
Case15:
A 42YR OLD MALE WITH FEVER AND COUGH.
Q1:As the patient is a non- diabetic, can the use of steroids cause transient rise in blood glucose?
Ans:Prednisone and other steroids can cause a spike in blood sugar levels by making the liver resistant to insulin.
Q2:If yes, can this transient rise lead to long term complication of New-onset diabetes mellitus?
Ans:yes, it can lead to new onset of dm .
Q3:How can this adversely affect the prognosis of the patient?
Ans:People with hyperglycemia and related comorbidities are at increased risk of severe COVID-19 complications, and COVID-19-related mortality in this population is two to three times higher than that in people without diabetes.
Q4:How can this transient hyperglycemia be treated to avoid complications and bad prognosis?
Ans:An intravenous insulin infusion is the safest and most effective way to treat hyperglycemia in critically ill patients. A glycemic target of 140 to 180 mg/dL is recommended for critically ill patients.
Q5:What is thrombophlebitis fever?
Ans:Low grade fever may accompany superficial and deep phlebitis. High fever or drainage of pus from the site of thrombophlebitis may suggest an infection of the thrombophlebitis
Q6:Should the infusion be stopped inorder to control the infusion thrombophlebitis? What are the alternatives?
Ans:yes. Warm water compress is an alternative.
CASE 16:
Viral Pneumonia Secondary to COVID-19
Q1: What could be the possible factors implicated in elevated glycated HB ( HBA1c ) levels in a previously Non-Diabetic covid patient?
Ans:Increased red cell turnover: blood loss, haemolysis, haemoglobinopathies and red cell disorders, myelodysplastic disease.
Q2:What is the frequency of this phenomenon of New Onset Diabetes in Covid Patients and is it classical type 1 or type 2 or a new type?
Ans: type1 diabetes
Q3:How is the prognosis in such patients?
Ans : poor prognosis .People with diabetes with COVID-19 are at a greater risk of worse prognosis and mortality. Given the high worldwide prevalence of diabetes, these individuals represent a large vulnerable segment of the COVID-19 population. The poorer prognosis of people with diabetes is the likely consequence of the syndromic nature of the disease . hyperglycaemia, older age, comorbidities, and in particular hypertension, obesity, and cardiovascular disease all contribute to increase the risk in these individuals.
Q4:Do the alterations in glucose metabolism that occur with a sudden onset in severe Covid-19 persist or remit when the infection resolves?
Ans:
It might lead to new onset diabetes .
CASE17
A 62 YEAR OLD MALE PATIENT WITH FEVER , COUGH AND SHORTNESS OF BREATH
Q1:Does hypertension have any effect to do with the severity of the covid infection.If it is, Then how?
Ans: yes, the link between hypertension and COVID-19 is unclear. Severity of COVID-19 illness is skewed towards the elderly population who have a higher prevalence of hypertension.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.
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.
Q2:what is the cause for pleural effusion to occur?
Ans:The most common causes of pleural effusion are congestive heart failure, cancer, pneumonia, and pulmonary embolism.
CASE18:
https://meesumabbas82.blogspot.com/2021/05/a-38-yo-male-with-viral-pneumonia.htm
Viral Pneumonia Secondary to COVID-19
Q1:What is the reason for hypoalbuminemia in the patient?
Ans:
It may be due to pulmonary capillary leakage in lungs , in response to epithelial endothelial damage due to covid infection.
Question 2:
What could be the reason for exanthem on arms? Could it be due to covid-19 infection ?
Ans:
Yes, what the patient is experiencing is known as viral exanthem which is one of the cutaneous manifestation of COVID-19.
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
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:19
1)Can usage of steroids in diabetic Covid patients increases death rate because of the adverse effects of steroids???
Ans:yes,steroids are used to supress the immune system. The most common adverse affects of steriods are increasing blood sugar levels .When the patient is on steroids and is a diabetic, the blood sugar levels have to be monitored time to time.
Q2:Why many COVID patients are dying because of stroke though blood thinners are given prophylactically???
Ans: Patients given preventive blood thinning drugs (prophylactic anticoagulants) within 24 hours of admission to hospital with covid-19 are less likely to die compared with those who do not receive them.
Q3:Does chronic alcoholism have effect on the out come of Covid infection????
If yes,how??
Ans:alcohol compromises the body's immune system and increases the risk of adverse health outcomes.
CASE20:
Q1:What can be the causes of early progression and aggressive disease(Covid) among diabetics when compared to non diabetics?
Ans:Chronic inflammation, increased coagulation activity, immune response impairment, and potential direct pancreatic damage by SARS-CoV-2 might be among the underlying mechanisms of the association between diabetes and COVID-19.
Q2:. In a patient with diabetes and steroid use what treatment regimen would improve the chances of recovery?
Ans: monitoring the blood glucose levels from time to time and administering sc HAI to the patient.
Q3:What effect does a history of CVA have on COVID prognosis
Ans:history if this increases the risk if death and leads to poor prognosis.
CASE21:
VIRAL PNEUMONIA SECONDARY TO COVID 19
Q1:What do you think are the factors in this patient that are contributing to his increased severity of symptoms and infection?
Ans:type 2 diabetes , CKD, pulmonary kochs, bronchial asthma, chronic NSAID use.
Q2:Can you explain why the D dimer levels are increasing in this patient?
Ans: the patient is a known case of Chronic kidney disease and it could be a reason for increased d dimer levels.
Q3:What were the treatment options taken up with falling oxygen saturation?
Ans:O2 supplementation with 15 L/min
Q4:Can you think of an appropriate explanation as to why the patient has developed CKD, 2 years ago? (Note: Despite being on anti diabetic medication, there was no regular monitoring of blood sugar levels and hence no way to know for sure if it was being controlled or not)
Ans:The high levels of sugar in the blood damage the millions of nephrons within each kidney. This eventually leads to kidney failure.
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