Medicine blended assignment (may)

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

This is 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 comprehension of the cases.


1A CASE:

"A 57 year old female with shortness of breath, pedal edema and facial puffiness.

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

Q1:What is the evolution of 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:
Symptomatology in event timeline in this patient:
The patient had shortness of breath on and off for past 20 years.

                             First episode was 20 years ago in the month of january while she was working in a paddy field.it lasted for about a week.
she had suffered similar episodes of shortness of breath every year in the month of january while working in the paddy fields for next 8 years.
12 years ago she had another episode of shortness of breath lasted for 20 days.
since then there were yearly episodes lasting for about a month around the month of january.
Her latest episode of shortness of breath was 30 days ago.
Other symptoms are: generalized weakness one month ago, pedal edema since 15 days, facial puffiness since 15 days.
Anatomical localization of the problem:
Bronchi and bronchioles.
Primary etiology:
Due to ongoing causative exposure (paddy dust in this case) airflow limitation is usually progressive and associated with an abnormal inflammatory response of lungs.

Q2: What are mechanism of action, indication,, and efficacy over placebo of each of the pharmacological and non pharmacological interventions used for this patient?
Ans: 
HEAD END ELEVATION: It improves end expiratory lung volumes. It has been shown to assist in reducing respiratory complications.
O2 INHALATION: to maintain SPO2 above 92%.
BiPAP: it provides 2 different levels of air pressure, which makes breathing out easier. It lessens the work it takes to breathe, which is important in people with COPD who expend a lot of energy breathing.
AUGUMENTIN: it is an antibiotic medication used to treat many bacterial infections. It consists of amoxicillin and potassium clavulanate.
AZITHROMYCIN: It is an antibiotic. It may offer relief for patients with COPD. Antibiotics can reduce treatment failure in patients hospitalized with an acute exacerbation of the disease. it reduces the inflammation in lungs.
LASIX: It is a prescription medicine used to treat the symptoms of fluid retention(edema). It works by blocking the absorption of sodium, chloride, and water from the filtered tubules causing a profound increase in outcome of urine(diuresis).
PANTOP: It is commonly used for diagnosis or treatment of gastro esophageal reflux disease, heartburn, esophagus inflammation, stomach ulcers.
HYDROCORTISONE: Steroids are among the medications commonly prescribed to patients with COPD. They help reduce the inflammation the lungs caused by flare ups. 
NEBULIZATION WITH IPRAVENT: Ipratropium is an acetylcholine antagonist via blockade of muscarinic cholinergic receptors. Blocking cholinergic receptors decreases the production of cGMP. This decreases in the lung airways will lead to decreased contraction of smooth muscles. This makes breathing less difficult.
NEBULIZATION WITH BUDECORT: Budesonide belongs to a class of drugs known as corticosteroids. It is a medicine used for asthma and COPD. It directly works in the lungs to make breathing easier by reducing the irritation and swelling of airways. It is called a preventive inhaler because it helps patient from getting symptoms.
PULMOCLEAR TABLETS: It is combination of two mucolytic medicines namely: acebrophylline and acetylcysteine. It thins and loosens mucus making it easier to cough out. It is used for relieving the symptoms of coughing, wheezing, congestion and blockade in the airways in a condition called COPD.
CHEST PHYSIOTHERAPY: Is a group of physical techniques that improve lung function and helps the patient feel better. Chest PT expand the lungs, strengthens the breathing muscles, and loosens and improves drainage of thick lung secretions.
INJ HAI: It is short acting type of insulin for controlling blood sugar levels. It is used to treat type 1 and type 2 diabetes mellitus.
INJ THIAMINE: Thiamine is important in the breakdown of carbohydrates from foods into products needed by the body. It is used to treat or prevent vitamin B1 deficiency.
GRBS : to monitor blood glucose levls
vitals monitoring
I/o charting

Q3: What could be cause for her current acute exacerbation?
Ans:
  • Respiratory infection. Common bacterial pathogens of acute exacerbations include Hemophilus influenzae, streptococcus pneumoniae, moraxella catarrhalis etc.
  • Allergens, eg: pollens, paddy dust in this case, wood or cigarette smoke, pollution.
  • Toxins, including variety of different chemicals.
  • Air pollution
  • Failing to follow a drug therapy program, eg: improper use of an inhaler.
Q4: Could the ATT have affected her symptoms? if so how?
Ans:
yes. theoretically, delay or non adherence in the anti tubercular treatment may increase the severity of airway inflammation thus rendering the development of COPD. However the association between anti tubercular treatment and COPD has never been elucidated.

Q5:What could be the cause of her electrolyte imbalance?
Ans:
Patients with acute exacerbations of COPD not only present with the features of acute respiratory infections but also a number of metabolic disorders like hyponatremia, hypokalemia, elevated blood urea, elevated serum creatinine arising out of the disease process or as a consequence of the therapy such as beta2 agonists, steroids etc.
water retention and hyponatremia are typically observed in final stages of COPD patients and the onset of edema is the poor prognostic factor.
Gas exchange impairment induces several hormonal abnormalities: renin, angiotensin II, aldosterone, ANP, ADH are some of the factors involved.
This patient has hyponatremia and hypochloremia. Hyponatremia can occur in COPD patients as a manifestation of secondary water retention in comorbidities such as heart or renal failure.


2A CASE:

"Altered sensorium in 40 year old male patient"

https://143vibhahegde.blogspot.com/2021/05/wernickes-encephalopathy.html 

Q1: 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 patient's problem?
Ans: 
EVOLTION OF SYMPTOMATOLOGY :The patient had 2-3 episodes of seizures, one being one year ago and the other being 4 months ago. He had developed seizures following cessation of alcohol for 24hours which was associated with restlessness, sweating, and tremors. 9 days ago the patient started talking and laughing to him self. He had short term memory loss since 9 days, where he could not recognize family members from time to time.
ANATOMICAL LOCALIZATION: Peripheral and central nervous system.
PRIMARY ETIOLOGY OF PATIENT'S PROBLEM:
Wernicke's encephalopathy is due to brain damage caused by lack of vitamin B1. Lack of vitamin B1 is common in people who have alcohol use disorder. 

Q2: What are mechanism of action, indication and efficacy over placebo of each of pharmacological and non pharmacological interventions used for this patient?
Ans:
IVF NS and RL: Normal saline is a cornerstone of intravenous solutions commonly used in clinical setting. It is a crystalloid fluid administered via an intravenous solution. It's indications include both adult and pediatric populations as sources of hydration and electrolyte disturbances. Ringer's lactate solution also known as sodium lactate solution or hartmann's solution. It is a mixture of sodium chloride, sodium lactate, potassium chloride, and calcium chloride in water. It is used for replacing fluids and electrolytes in those who have low blood volume or low blood pressure.
Inj THIAMINE: Thiamine replacement is the primary treatment for wernicke's encephalopathy in order to reverse mental status changes and prevent further disease progression. Parenteral thiamine is used in the acute treatment of wernicke's since intestinal absorption of thiamine may be impaired as in case of alcoholics.
LORAZEPAM Inj: It is a benzodiazepine. It is used to treat seizures including status epilepticus, alcohol withdrawal, chemotherapy induced nausea and vomiting. 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 cells.
PREGABLIN: It is an anticonvulsant and anxiolytic medication used to treat epilepsy, neuropathic pain, fibromyalgia, generalized anxiety disorder.
Inj HAI: It is short acting type of insulin for controlling blood sugar levels. It is used to treat type 1 and type 2 diabetes mellitus.
GRBS: To monitor blood glucose levels.
LACTULOSE: It is a laxative taken to treat constipation.it is used to prevent complications of hepatic encephalopathy.it may also help to improve mental status.
Inj ampoule KCL in 10 NS: it is used to treat symptoms of hypokalemia, prophylaxis for hypokalemia, iv intermittent infusions. KCL in NS belongs to the class of drugs called electrolyte supplements.
SYP POTCHLOR: It is used to treat low levels of potassium in the body. It is a oral solution containing potassium chloride as an active ingredient.


Q3:Why have the neurological symptoms appear this time, that were absent during withdrawal earlier? what could be the possible cause for this?
Ans:
These neurological symptoms can occur following a reduction in alcohol use after a period of excessive use. As per the history, the patient had consumed one bottle of alcohol. so, this could be the cause for the neurological symptoms this time.

Q4:WHAT IS THE REASON FOR GIVING THIAMINE IN THIS PATIENT?
Ans:
Thiamine is useful in preventing wernicke's encephelopathy, an acute disorder due to thiamine deficiency manifested by confusion, ataxia, and ophthalmoplegia. thiamine has no effect on the signs and symptoms of alcohol withdrawal or on the incidence of seizures .

Q5: What is the probable reason for kidney injury in this patient?
Ans: 
The sudden removal of alcohol can kidney failure. Excessive amounts of alcohol can cause imbalance in the electrolytes as well as an acid base imbalance. the imbalances can eventually lead to kidney failure.

Q6: What is the probable cause for normocytic anemia?
Ans: it could be due to uremic encephalopathy .

Q7: Could chronic alcoholism have aggravated the foot ulcer formation? if yes, how and why?
Ans:
yes, consumption of alcohol can worsen the formation of ulcer.


2B CASE:

A 52 YEAR OLD MALE WITH CEREBELLAR ATAXIA.

https://kausalyavarma.blogspot.com/2021/05/a-52-year-old-male-with-cerebellar.html?m=1

Q1: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:

EVOLUTION OF SYMPTOMATOLOY :patient had history of giddiness 7 days back. It started at around 7 am when the patient was doing his usual morning routine. He suddenly felt giddy and took rest, after which it subsided briefly. This was associated with 1 episode of vomiting on the same day.

- Patient was asymptomatic for 3 days, after which he consumed a small amount of alcohol.

- He then developed giddiness, that was sudden in onset, continuous and gradually progressive. It increased in severity upon getting up from the bed and while walking.

- This was associated with Bilateral Hearing loss, aural fullness and presence of tinnitus.

- He has associated vomiting- 2-3 episodes per day, non projectile, non bilious containing food particles.

- Patient has H/o postural instability- he is unable to walk without presence of supports, swaying is present and he has tendency to fall while walking 

ANATOMICAL LOCALIZATION: Cerebellar ataxia is a form of ataxia originating in the cerebellum.
ETIOLOGY:
Damage, degeneration or loss of nerve cells in the cerebellum results in ataxia. some of the causes include head trauma, stroke, cerebral palsy, autoimmune disorders, infections, paraneoplastic syndromes, toxic reactions, vitamin E,B12 or thiamine deficiency, 

Q2: What are mechanism of action, indication and efficacy over placebo of each of the pharmacological and non pharmacological interventions used for this patient?
Ans:
VERTIN: it is used to prevent and treat a disorder of inner ear known as meniere's disease.it is an antihistamine that is used to treat nausea, vomiting, and dizziness.
ZOFER inj: it contains ondansetron. it is used to control nausea and vomiting.
ECOSPRIN: it contains aspirin. It belongs to class NSAIDS. It is used to prevent blood clot formation.
ATORVOSTATIN: it belongs to group of medicines called statins. It reduces the risk of stroke.
BP MONITORING
CLOPIDOGREL: it is an anti platelet medicine. it prevents platelets from sticking together and forming a blood clot. 
THIAMINE: Parenteral thiamine is used in prevention of wernicke's since intestinal absorption of thiamine may be impaired as in case of alcoholics.

Q3:Did the patients history of de novo HTN contribute to his current condition?
Ans:
yes, that could be a possible reason. A high intra luminal pressure will lead to extensive alteration in endothelium and smooth muscle function in intracerebral arteries.
The increased stress on the endothelium can increase permeability over the blood brain barrier and local or multifocal brain edema.
Endothelial damage and altered blood cell endothelium interaction can lead to local thrombi formation and ischemic lesions.
Furthermore, hypertension accelerates the arteriosclerotic process.

Q4: Does the patient's history of alcoholism make him more susceptible to ischemic or hemorrhagic type of stroke?
Ans:
yes, regular heavy alcohol consumption increases the risk for ischemic stroke.





A 45 YEAR OLD FEMALE PATIENT WITH PALPITATIONS, PEDAL EDEMA, RADIATING PAIN ALONG LEFT UPPER LIMB.


http://bejugamomnivasguptha.blogspot.com/2021/05/a-45-years-old-female-patient-with.html

Q1: 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:
 SYMPTOMATOLOGY: 
Patient has developed bilateral pedal edema 8 months back, it is present both in sitting and standing position.
She has palpitations since 5 days.
Dyspnoea during palpitations since 5 days.
Pain since 6 days radiating along the left upper limb which is dragging in nature, aggravated during palpitations.
Chest pain is associated with chest heaviness.
ANATOMICAL LOCALISATION: bones, discs, and joints of the neck.
ETIOLOGY:
Risk factors for cervical spondylosis include:
  • Age: cervical spondylosis is the normal part of ageing
  • Occupation: occupations that involve repetitive neck motions, stress on neck
  • Neck injuries
  • Genetic factors
  • Smoking
Causes of cervical spondylosis includes : dehydrated discs, herniated discs, bone spurs, stiff ligaments.

Q2:What are the reasons for recurrence of hypokalemia in her? Important risk factors for her hypokalemia?
Ans:
Hypokalemia has many causes. the most common cause is usage of diuretics.
Risk factors for hypokalemia:
Female gender, diuretics, heart failure, hypertension, low BMI, etc.

Q3: What are the changes seen in ECG in case of hypokalemia and associated symptoms?
Ans:
ECG changes includes flattening and inversion of T waves, in mild hypokalemia, followed by Q-T interival prolongation, visible U wave and mild ST depression.



2D CASE:

A 55 YEAR OLD PATIENT WITH SEIZURES

https://rishikoundinya.blogspot.com/2021/05/55years-old-patient-with-seizures.html

Q1:s there any relationship between occurrence of seizure to brain stroke. If yes what is the mechanism behind it?
Ans:
If a patient have had a stroke then, he have an increased risk for having a seizure. stroke causes brain to become injured. The injury to the brain results in the formation of scar tissue, which affects the electrical activity in the brain. Disrupting the electrical activity can cause seizures.

Q2: 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?
Ans:
Abnormal increased activity in the fronto parietal association cortex and related sub cortical structures is associated with loss of consciousness in generalized seizures.


2E CASE:

A 48 YEAR OLD MALE WITH SEIIZURES AND ALTERED SENSORIUM

https://nikhilasampathkumar.blogspot.com/2021/05/a-48-year-old-male-with-seizures-and.html?m=1


Q1: What could have been the reason for this patient to develop ataxia in the past 1 year?
Ans:
As per the history the possible cause could be multiple head injuries (external trauma) and alcohol intoxication.

Q2: What was the reason for his IC bleed? Does Alcoholism contribute to bleeding diatheses ?
Ans: 
The reason for IC bleed could be due to head trauma. yes, excessive alcohol consumption contributes to bleeding diathesis.


2F CASE:

A 30 year old male patient with weakness of right upper limb and lower limb

http://shivanireddymedicalcasediscussion.blogspot.com/2021/05/a-30-yr-old-male-patient-with-weakness.html

Q1:Does the patient's history of road traffic accident have any role in his present condition?
Ans:
yes, it might have a role in in his present condition,

Q2:What are the warning signs of CVA?
Ans:
Sudden numbness or weakness in the face, arm, or leg especially on one side of the boody.
  • Sudden confusion, trouble speaking, or difficulty understanding speech.
  • Sudden trouble seeing in one or both eyes.
  • Sudden trouble walking, dizziness, loss of balance, or lack of coordination.
  • Q3:What is the drug rationale in CVA?
  • Ans:
  • Antiplatelet drugs, anti coagulant drugs,, neuro protective agents, hemodilution, vasodilators, thrombolysis.

Q4:Does alcohol have any role in his attack?
Ans:
yes, consumption of alcohol contributes to many risk factors that lead to CVA.

Q5:Does his lipid profile has any role in his attack?
Ans:
No, the patient's lipid profile is normal.


A 50 YEAR OLD PATIENT WITH CERVICAL MYELOPATHY
Q1:What is myelopathy hand?
Ans: 
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.

Q2:What is finger escape ?
Ans:
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".

Q3:What is Hoffman’s reflex?
Ans:
The Hoffman sign is an involuntary flexion movement of the thumb and or index finger when the examiner flicks the fingernail of the middle finger down. The reflexive pathway .

2H CASE:

A 17 YEAR OLD FEMALE WITH SEIZURES
https://neerajareddysingur.blogspot.com/2021/05/general-medicine-case-discussion.html?m=1
Q1:What can be the cause for her condition?
Ans:
Causes of seizures can include:
  • Abnormal levels of sodium or glucose in the blood.
  • Brain infection, including meningitis and encephalitis.
  • Brain injury that occurs to the baby during labor or childbirth.
  • Brain problems that occur before birth (congenital brain defects)
  • Brain tumor (rare)
  • Drug abuse.
  • Electric shock
Q2:what are the risk factors for cortical vein thrombosis?
Ans:
  • 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.
Q3: what drug was used in suspicion of cortical venous sinus thrombosis?
Ans:Acitrom tablet is an oral anticoagulant medicine that is used for the treatment and prevention of the formation of abnormal blood clots (thrombus) in blood vessels and disease associated with it affect.

3A case:

A 78YEAR OLD MALE WITH SHORTNESS OF BREATH, CHEST PAIN, B/L PEDAL EDEMA AND FACIAL PUFFINESS

https://muskaangoyal.blogspot.com/2021/05/a-78year-old-male-with-shortness-of.html
Q1:1.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

Q3:What are the risk factors for development of heart failure in the patient?

Ans:
  • High blood pressure. Your heart works harder than it has to if your blood pressure is high.
  • Coronary artery disease. 
  • Heart attack. 
  • Diabetes. 
  • Some diabetes medications. 
  • Certain medications. 
  • Sleep apnea. 
  • Congenital heart defects.
3B CASE: 
A 73 YEAR OLD MALE PATIENT WITH PEDAL EDEMA, SHORTNESS OF BREATH AND DECREASED URINE OUTPUT. 


Q1:what are the possuble reasons for heart failure?
Ans:
Smoking. 
  • Poor diet.
  • High blood pressure. 
  • High blood cholesterol levels. 
  • Diabetes.
Q2:what is the reason for anaemia in this case?
Ans: CKD
Q3:What is the reason for blebs and non healing ulcer in the legs of this patient?
Ans: it might be due to diabetes mellitus
Q4:Why was the patient asked to get those APTT, INR tests for review?
Ans:


3C CASE:

A-Fib and Biatrial Thrombus in a 52yr old Male

https://preityarlagadda.blogspot.com/2021/05/biatrial-thrombus-in-52yr-old-male.html
Q1: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:
  • Patient was apparently asymptomatic 2 days ago when he developed Shortness of breath Grade II (on exertion) which progressed to Grade IV (at rest) 
  • Patient also complains of decreased urine output since 2 days and Anuria since morning.
Anatomical localisation: heart
Primary etiology: Loss of Atrial contraction and Left atrial dilatation causes stasis of blood in the LA and may lead to Thrombus formation in the Left Atrial Appendage. This predisposes patients to stroke and other forms of systemic embolism.

Q2) What are mechanism of action, indication and efficacy over placebo of each of the pharmacological and non pharmacological interventions used for this patient?
Ans:
Cardivas:
Cardivas 3.125 Tablet is a medicine used to treat high blood pressure, heart-related chest pain (angina), and heart failure. It works by relaxing the blood vessels, so blood can flow more easily to the heart. Lowering blood pressure also helps prevent future heart attacks and stroke
Dytor:It is commonly used for the diagnosis or treatment of High Blood pressure, excessive accumulation of water in the body.
Pan D:It is commonly used for the diagnosis or treatment of Heavy bloating, Gas, Heartburn, Indestion, Fullness of stomach
Taxim:Taxim-O 200 tablet is an antibiotic medicine, used to treat bacterial infections of the urinary tract, lungs, throat, airways, gallbladder and bile duct

Q3: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, a complex pathophysiological disorder of both the heart and kidneys, is a condition in which acute or chronic damage to one organ can lead to acute or chronic dysfunction of the other organ. Depending on primary organ dysfunction and disease duration, there are five different types of cardiorenal syndrome. Type 1 cardiorenal syndrome (acute cardiorenal syndrome) is defined as acute kidney injury caused by sudden decrease in heart function. Type 2 cardiorenal syndrome (chronic cardiorenal syndrome) refers to chronic kidney disease linked to chronic heart failure. Type 3 cardiorenal syndrome (acute renocardial syndrome) is caused by acute kidney injury that leads to heart failure. Type 4 cardiorenal syndrome (chronic renocardial syndrome) includes chronic heart failure due to chronic kidney disease. Type 5 cardiorenal syndrome (secondary cardiorenal syndrome) is reversible or irreversible condition marked by simultaneous heart and kidney insufficiency, as a result of multiorgan disease such as sepsis, diabetes mellitus, sarcoidosis, amyloidosis, etc. The pathophysiological patterns of cardiorenal syndrome are extremely complicated.
Q4: What are the risk factors for atherosclerosis in this patient?
Ans:
Hypertension 


3D CASE:

67 year old patient with acute coronary syndrome

https://daddalavineeshachowdary.blogspot.com/2021/05/67-year-old-patient-with-acute-coronary.html?m=1
Q1: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:patient had H/O heartburn like episodes since a year. 
H/O TB diagnosed 7 months ago
shortness of breath (SOB) since 1/2 hour.
Anatomical localisation: walls of arteries of heart .
Primary etiology:
Acute coronary syndrome usually results from the buildup of fatty deposits (plaques) in and on the walls of coronary arteries, the blood vessels delivering oxygen and nutrients to heart muscles. When a plaque deposit ruptures or splits, a blood clot forms. This clot blocks the flow of blood to heart muscles.

Q2:What are mechanism of action, indication and efficacy over placebo of each of the pharmacological and non pharmacological interventions used for this patient?
Ans:
MET XL:It is commonly used for the diagnosis or treatment of angina pectoris, cardiac arrhythmias, heart failure
Q3:What are the indications and contraindications for PCI?
Ans: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.

    3E CASE:

  • https://bhavaniv.blogspot.com/2021/05/case-discussion-on-myocardial-infarction.html?m=1 ACUTE MYOCARDIAL INFARCTION

  • Q1: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: Patient was apparently asymptomatic  3 days back and then he developed mild chest pain in the right side of the chest. The pain was insidious in onset and gradually progressive.
  • Anatomical localisation: blood vessels
  • Primary etiology: ETIOLOGY:

    Causes:

    • Atherosclerosis – Also known as coronary artery disease, this condition is the most common cause of heart attacks and occurs when the buildup of fat, cholesterol, and other substances forms plaque on the walls of the coronary arteries
    • Coronary artery spasm – A rare cause of blockage, spasms of the coronary arteries can cause them to become temporarily constricted. 
    • Coronary artery tear – Also known as a spontaneous coronary artery dissection, a tear in a coronary artery can prevent blood from reaching the heart and cause a heart attack.
    Q2:What are mechanism of action, indication and efficacy over placebo of each of the pharmacological and non pharmacological interventions used for this patient?
    Ans:ASPIRIN:Aspirin, also known as acetylsalicylic acid, is a medication used to reduce pain, fever, or inflammation. Specific inflammatory conditions which aspirin is used to treat include Kawasaki disease, pericarditis, and rheumatic fever. Aspirin given shortly after a heart attack decreases the risk of death.
    ATORVAS:Atorvastatin belongs to a group of medicines called statins. It's used to lower cholesterol.It's also taken to prevent heart disease, including heart attacks and strokes.
    CLOPIBB:Clopitab 75 mg Tablet is used to prevent blood clot formation in the hardened blood vessels thus reducing the risk of heart attack, stroke, heart-related chest pain.
    HAI 6U/IV STAT: to control hyperglycemia

    Q3: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. 

    3F CASE:

    Q1:How did the patient get  relieved from his shortness of breath after i.v fluids administration by rural medical practitioner?
    Ans:
    Because of the fluid loss occured to the patientThere is decreased preload → SOB occured due to decreased cardiac output
    IV fluids administered → there is increase in preload → SOB decreased due to better cardiac output

    2. What is the rationale of using torsemide in this patient?
    Torsemide is used due to abdominal distension

    3. Was the rationale for administration of ceftriaxone? Was it prophylactic or for the treatment of UTI?
    Treatment for UTI
    Rationale - used for any bacterial infection 

    4A case:

    A 33 YEAR OLD MAN WITH PANCREATITIS, PSEUDOCYST AND LEFT BRONCHO-PLEURAL FISTULA


    Q1: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:Patient was apparently asymptomatic 5 yrs back when he had painabdomen & vomitings.Following that he stopped taking alcohol as advised by the physician and was symptom free for nearly 3 yrs.Later he again started taking alcohol following which he had recurrent episodes of pain abdomen & vomiting  (5-6 episodes in the past 1 year) .From the past 20 days he had increased amount alcohol consumption (5 bottles of toddy per day) Last binge of  alcohol 1 week back following which he again had pain abdomen & vomiting from 1 week and fever from 4 days. abdominal pain in umbilical, left hypochondriac, left lumbar and hypogastric regions.
    patient also had burning micturition since 4 days.Then he developed constipation since 4 days and passing flatus. Fever was high grade, continuous.
    Anatomical localisation: pancreas
    Primary etiology: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

    Q2: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?
    Ans:
    Meropenem injection is used to treat skin and abdominal (stomach area) infections caused by bacteria and meningitis (infection of the membranes that surround the brain and spinal cord) in adults and children 3 months of age and older. Meropenem injection is in a class of medications called antibiotics.
    METROGYL:Metrogyl is used to treat certain infections caused by bacteria and other organisms in different parts of the body. Metrogyl may also be used to prevent or treat certain infections that may occur during surgery. Metrogyl is an antibiotic which belongs to a group of medicines called nitroimidazoles.
    AMIKACIN:Amikacin is an antibiotic medication used for a number of bacterial infections. This includes joint infections, intra-abdominal infections, meningitis, pneumonia, sepsis, and urinary tract infections. It is also used for the treatment of multidrug-resistant tuberculosis.
    TPN ( Total Parenteral Nutrition ):Total parenteral nutrition (TPN) is a method of feeding that bypasses the gastrointestinal tract. Fluids are given into a vein to provide most of the nutrients the body needs.
    OCTREOTIDE:Octreotide immediate-release injection is used to decrease the amount of growth hormone (a natural substance) produced by people with acromegaly (condition in which the body produces too much growth hormone, causing enlargement of the hands, feet, and facial features; joint pain; and other symptoms)
    PANTOP:It is commonly used for the diagnosis or treatment of Gastro-esophageal reflux disease, Heartburn, Euophagus inflammation, Stomach ulcers.
    ING. THIAMINE:treat and prevent Wernicke-Korsakoff syndrome (tingling and numbness in hands and feet, memory loss, confusion caused by a lack of thiamine in the diet.
    TRAMADOL:Tramadol is used to relieve moderate to moderately severe pain.

    4B case:

    25 YEAR OLD MALE WITH EPIGASTRIC PAIN


    Q1:What is causing the patient's dyspnea? How is it related to pancreatitis?
    Ans:
    It might be due to pleural effusion.
    With severe pancreatitis there are a lot of inflammatory chemicals that are secreted into the blood stream. These chemicals create inflammation throughout the body, including the lungs.

    Q2: Name possible reasons why the patient has developed a state of hyperglycemia.
    Ans:This hyperglycemia could thus be the result of a hyperglucagonemia secondary to stress or the result of decreased synthesis and release of insulin secondary to the damage of pancreatic β-cells.

    Q3:What is the reason for his elevated LFTs? Is there a specific marker for Alcoholic Fatty Liver disease?
    Ans:
    Determine alkaline phosphatase, total bilirubin, aspartate aminotransferase (AST), and alanine aminotransferase (ALT) levels to search for evidence of gallstone pancreatitis. An ALT level higher than 150 U/L suggests gallstone pancreatitis and a more fulminant disease course.
    Q4:What is the line of treatment in this patient?
    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

    4C CASE:

    A 45 year old Female patient with Fever, Pain abdomen, Decreased Urine output and Abdominal distension

    Q1:what is the most probable diagnosis in this patient?
    Ans:Ruptured Liver Abscess.
    Organized collection secondary to Hollow viscous Perforation.
    Q2:What was the cause of her death?
    Ans:
    It can be due to complications of laprotomy surgery.
    Q3: Does her NSAID abuse have  something to do with her condition? How?
    Ans:NSAID-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.

    5A CASE:

    Post TURP with non oliguric ATN

    Q1:What could be the reason for his SOB?
    Ans: due to acidosis which was caused by diuretics.
    Q2:Why does he have intermittent episodes of  drowsiness ?
    Ans:hyponatremia 
    Q3:Why did he complaint of fleshy mass like passage in his urine?
    Ans:as there are many pus cells in the urine passage they appeared as fleshy masses. 
    Q4:What are the complications of TURP that he may have had?
    Ans:difficulty in micturition , electrolyte imbalance and infections.

    5B CASE:

    An Eight year old with Frequent Urination

    Q1:Why is the child excessively hyperactive without much of social etiquettes ?
    Ans:suggests that a reduction in dipamine is a factor in ADHD. Dopamine is a chemical in the brain that helps move signals from one nerve to another. It plays a role in triggering emotional responses and movements.

    Other reseaches suggests a structural difference in the brain. Findings indicate that people with ADHD have less gray matter volume. Gray matter includes the brain areas that help with:

    • speech
    • self-control
    • decision-making
    • muscle control
    Q2:Why doesn't the child have the excessive urge of urination at night time ?
    Ans:ADHD is a psycosomatic disorder.

    Q3:How would you want to manage the patient to relieve him of his symptoms?
    Ans:Behavioral therapy, also known as behavior modification, has been shown to be a very successful treatment for children with ADHD. It is especially beneficial as a co-treatment for children who take stimulant medications and may even allow you to reduce the dosage of the medication.

    6A CASE:

    A 40 YEAR OLD LADY WITH DYSPHAGIA, FEVER AND COUGH

    Q1:.Which clinical history and physical findings are characteristic of tracheo esophageal fistula?
    Ans:The cough occurs on taking food and liquids.
    Q2:What are the chances of this patient developing immune reconstitution inflammatory syndrome? Can we prevent it? 
    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.

    7A CASE:

    Liver Abscess

    Q1:Do you think drinking locally made alcohol caused liver abscess in this patient due to predisposing factors
     present in it ? 
    Ans: Yes, it could be due to contaminated toddy.
    Q2:What is the etiopathogenesis  of liver abscess in a chronic alcoholic patient ? ( since 30 years - 1 bottle per day)
    Ans:
    The usual pathophysiology for pyogenic liver abscesses is bowel content leakage and peritonitis. Bacteria travel to the liver via the portal vein and resides there. Infection can also originate in the biliary system. Hematogenous spread is also a potential etiology.
    Q3:Is liver abscess more common in right lobe ?
    Ans: right lobe is more involved due to it's more blood supply.
    Q4: What are the indications for ultrasound guided aspiration of liver abscess ?
    Ans: large abscess more than 6 cms
            Left lobe abscess
             Caudate lobe abscess 
              Abscess which is not responding to drugs.

    7B CASE:

    LIVER ABCESS

    Q1:Cause of liver abcess in this patient ?
    Ans:
    Entamoeba histolytica
    Q2:How do you approach this patient ?
    Ans:Approach in the patient of amoebic liver abscess
    Q3:Why do we treat here ; both amoebic and pyogenic liver abcess? 
    Ans:so that we don't rely only on anti amoebic therapy and ensure complete treatment of the cause. 
    Q4:Is there a way to confirmthe definitive diagnosis in this patient?
    Ans: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).

    8A CASE:

    50/Male came with altered sensorium

    Q1: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:Patient was apparently asymptomatic 3 years back and went to local hospital in/v/o Regular checkup and came to diagnosed with Hypertension since then he was on regulate medication... 
    And on 18/04/21 He went to local PHC for COVID 19 vaccination.. Since that night patient is complaining of Fever associated with chills and rigors, high grade fever.
    Followed by patient is having similar complaints after three days and he visited local hospital which is not subsided by medication.On 28/04/21 , c/o Generalized weakness and facial puffiness and periorbital edema.. And also patient is in drowsy state.. 
     On 04/05/21, patient presented to casualty In altered state with facial puffiness and periorbital edema and weakness of right upper limb and lower limb.
    Q2: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?
    Ans:
     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. 
    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
    Q3:  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.

    9th case:infectious disease

    Covid master chart

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