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MEDICINE BLENDED ASSIGNMENT [MAY 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, investigations and diagnosis and come up with a treatment plan.

LINK TO QUESTIONS REGARDING CASES


NAME : KATTEKOLA SATHWIK
ROLL NO : 58
8TH SEMESTER 


1. PULMONOLOGY

CASE 1

LINK TO PATIENT DETAILS 

QUESTIONS 
1) What is the evolution of the symptomatology in this patient in terms of an event timeline and where is the anatomical localisation for the problem and what is the primary etiology of the patient's problem?
ANSWER 
 EVOLUTION OF SYMPTOMATOLOGY 
# 20 YRS AGO: 1st attack of SOB 
#   every year from then in January: SOB lasting for a week 
# 12 YRS AGO: SEVERE SOB admitted for 20 days
#  every year till her current episode :in January 
# current episode : 
  • started 30 days ago
  • dyspnea on exertion and relieved on rest
  • but from 2 days, SOB is also at rest 

It is possible that attacks of SOB are triggered by winter season and dust [ as the patient experienced SOB in January  and while working in paddy fields ] every year. Continuous exposure to the inhalants would have triggered the progression of airway damage in the patient. This is evident by exacerbation of her symptoms every year. 

  Anatomical localisation: As evident by CT findings , the prime pathology is in the  Lower airways 

Prime etiology : chronic exposure to paddy dust 

Other symptoms
  • Pedal edema since 15 days  upto ankle .
  • Facial puffiness since 15 days.

 2. What are mechanism of action, indication and efficacy over placebo of each of the pharmacological and non pharmacological interventions used for this patient?
ANSWER
               The placebo gas no physiological and pharmacological actions in the body.

#Head end elevation 
  • Is used to improve ventilation .
  • Indicated in brain trauma , bed ridden patients, hypoxic patients.
# O2 inhalation 
  • Is used for improving the Spo2. 
  • It is indicated when there is less SPO2 die to lung pathology 
#Intermittent BiPaP 
  • Is used to  maintain breathing pattern.
  • Indicated in  lung diseases like severe COPD , COVID -19 etc..
Drug therapy 
1. Augmentin 
       It is a combination of Amoxicillin and clavulanic acid. Amoxicillin is a penicillin which is a cell wall synthesis inhibitor.
Penicillinase is an enzyme produced by the bacteria as a method of resistance to this antibiotic . Clavulanic acid inhibits the penicillinase thereby favouring the action of  Amoxicillin

This is used to control spectrum.of bacterial infections.
2.  Azithromycin 
           It is an antibiotic (Protein synthesis inhibitor) used to clear the bacterial infection in this patient which  is thought to be the cause of Acute exacerbation of SOB in this patient
3. Lasix injection
          It is a loop diuretic. 
         Acts by inhibiting Na k 2Cl channel
          This patient has pedal edema which is upto ankle and is pitting type. Loop diuretics like furosemide are effective in control of  pedal edema in this patient

4. Hydrocortisone 
            It is a steroid which os used to hasten the recovery in this patient. Enhancement in FEV1 and PaO2 in the patients  with acute exacerbation of the COPD was achieved with steroids . This drug also reduce the duration in stay of hospital and also reduces tge rate of relapse at a later date.

5. Nebulization with bronchodilators 
                Budecort and  Ipravent are the bronchodilators which are used to provide releif for acute attacks of dyspnea

6. Chest wall physiotherapy
          It enhances the compliance of the chestwall and aids in recovery. It also strengthens  the respiratory muscles.
7. GRBS charting
           It is used to monitor glucose levels
8. Temperature BP and SPO2 monitoring 
9. I/o charting
          It is Indicated in hypertensive and diabetic patients
10.Thiamine
           To prevent deficiency which may lead to neurological and cardiological deficits 

3) What could be the causes for her current acute exacerbation?
ANSWER
  • Acute bacterial infection
  • Overlying heart problem as suggested by Echocardiogram
  • Severe progression of disease.
  • Allergic response to paddy dust
  • Immunocompromised state as she is a diabetic and hypertensive.

4. Could the ATT have affected her symptoms? If so how?
ANSWER : yes ,generalised weakness and nephrotoxicity probably

5.What could be the causes for her electrolyte imbalance?
ANSWER
  • As her RFT is abnormal , I presume that her renal function is abnormal
  •  It could be a drug induced hyponatremia induced by  telmisartan  which she is using for hypertension

References
1. Robbins and cotrans pathologic basis of disease volume 2 10/e 

2. NEUROLOGY 

CASE :A
LINK TO PATIENT DETAILS

QUESTIONS
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?
ANSWER

Evolution of symptomatology in terms of an event time line

  • Episode of seizures 1 year ago
  • An episode of gtcs 4 months ago after cessation of alcohol for a day ( 24 hours)
  • Irrelevant improper behaviour, inability to get up from bed and assisted movement, decrease food intake and  short term memory loss since 9 days
Anatomical localisation:HIPPOCAMPUS AND FRONTAL LOBE

Prime etiology: CHRONIC ALCOHOLISM 

2) What are mechanism of action, indication and efficacy over placebo of each of the pharmacological and non pharmacological interventions used for this patient?
ANSWER
 Thiamine 
It helps the body cells change carbohydrates into energy. 
It has been used as a supplement to cope with thiamine deficiency

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

pregabalin
       It reduces the synaptic release of several neurotransmitters, apparently by binding to alpha 2-delta sub-units, and possibly accounting for its actions invivo to reduce neuronal excitability and seizures.

Lactulose
          It 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.

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?
ANSWER
     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?
ANSWER
             Thiamine deficiency is implicated in neurological deficits. So as to prevent further neurological problems due to thiamine deficiency ,thiamine is administered to the patient

5) What is the probable reason for kidney injury in this patient? 
ANSWER
               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.

6). What is the probable cause for the normocytic anemia?
ANSWER
  • ALCOHOL causes decreased iron absorption 
  • it also effects the hematopoietic system thereby reducing hematopoiesis
  • therefore, it causes NORMOCYTIC NORMOCHROMIC ANEMIA
 7) Could chronic alcoholism have aggravated the foot ulcer formation? If yes, how and why?
ANSWER  : YES 
REASON : 
# DIABETICS have an increased chances of ulcer formation
# as diabetes also delays the healing of ulcer
# chronic alcoholism weakens immune system , thereby aiding  the formation of healing 
     

CASE :B
LINK TO PATIENT DETAILS:
QUESTIONS
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?
ANSWER
Evolution of symptomatology in this patient in terms of an event timeline is as follows
 Day 1 :
  • The  patient had an episode of giddiness at 7:00 a.m. in the morning while he was doing his routine work whitch subsided upon taking rest. 
  • He also had an episode of vomiting on this day
Day 2 : Asymptomatic
Day 3: Asymptomatic
Day 4 : Asymptomatic
Day 5 : an episode of giddiness which is sudden onset after taking alcohol.
           Bilateral hearing loss ,aural fullness and tinnitus were present
          2 to  3 episodes of vomiting
          Postural instability was present
             The symptoms aggravated in the next 2 days and were  also associated with postural instability

Anatomical localisation of problem: cerebellum

Prime etiology : Long standing undiagnosed hypertension  and alcoholism which led to CVA
As suggested by CT


2) What are mechanism of action, indication and efficacy over placebo of each of the pharmacological and non pharmacological interventions used for this patient?
ANSWER
        The placebo has no physiological and pharmacological actions
1. Vertin
  • It is an anti vertigo medicine.
  • Composition: betahistine
  • Indications:.  Endolymphatic hydrops
  • It is an H1 receptor agonist and H3 receptor antagonist
2.Zofer
  • It is an anti-emetic
  • It is a serotonin antagonist
3. Clopidogrel
            It is an antiplatelet medication which is used in conditions such as impending stroke and in heart attack with aspirin

4. Atorvastatin
            It is a HMG-coA reductase inhibitor which is used to lower blood cholesterol 

5. Aspirin
            It is a NSAID which works by inhibiting cyclooxygenase.
It is used in people with heart diseases and in management of heart attack 
Most dangerous and rare side effect is Reyes syndrome

6. Multivitamin tablets
       These are used to prevent vitamin deficits and also help to replenish the stores of fat soluble vitamins

        
3) Did the patients history of denovo HTN contribute to his current condition?
ANSWER
              Considering the history and fact that hypertension is a risk factor for CVA we may presume that he might be a chronic hypertensive  which was undiagnosed.
Smoking and alcohol history would add weight to this presumption as they are thought to be the risk factors for hypertension.
Alcohol is an independent risk factor for stroke.

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


References
1. Robbins and cotrans pathologic basis of disease volume 1 10/e 


CASE C
LINK TO  PATIENT DETAILS

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

Questions:


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?
ANSWER
               The patient has palpitations,pedal edema ,chest pain and heaviness , dragging type of pain in left upper limb  all suggestive of a heart pathology

Previous history of hypokalemic paralysis suggestive of recurrent hypokalemic episodes
This might lead to auto compensation by kidney leading to reabsorption if the potassium along with water which might lead to pedal edema

Further the hypokalemia is known to cause  physiological heart defects and ECG changes which could Be the cause for palpitations and left upper limbs paralysis.



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

RISK FACTORS FOR HYPOKALEMIA 
# ABNORMAL LOSSES 
  • Medications:enema,diuretics,laxatives,steroids
  • renal causes: mineralocorticoid excess,osmotic diuresis,renal tubular acidosis,hypomagnesemia
# TRANS-CELLULAR SHIFTS 
  • alkalosis
  • thyrotoxicosis
  • delirium tremens
  • head injury
  • hypokalemic periodic paralysis
# Inadequate intake 


3) What are the changes seen in ECG in case of hypokalemia and associated symptoms
ANSWER
ECG changes in a case of hypokalemia are 
  • Earliest change in ECG:  Decreased T- wave amplitude
  • ST depression and T wave inversions
  • Prolonged PR interval.
  • U wave
  • Pseudo prolonged QT interval which actually is QU interval.
 In severe cases of hypokalemia ventricular fibrillation and  rarely AV block are seen.

CASE D 
Link to patient details 

QUESTIONS

1. Is there any relationship between occurrence of seizure to brain stroke. If yes what is the mechanism behind it?
ANSWER 
If you’ve had a stroke, you have an increased risk for having a seizure. A stroke causes your brain to become injured. The injury to your brain results in the formation of scar tissue, which affects the electrical activity in your brain. Disrupting the electrical activity can cause you to have a seizure.
 
  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?
ANSWER
Abnormal increased activity in fronto-parietal association cortex and related subcortical structures is associated with loss of consciousness in generalized seizures. Abnormal decreased activity in these same networks may cause loss of conscious-ness in complex partial seizures. Thus, abnormally increased or decreased activity in the same networks can cause loss of consciousness. Information flow during normal conscious processing may require a dynamic balance between these two extremes of excitation and inhibition.

REFERENCES

CASE E
LiNK TO PATIENT DETAILS


QUESTIONS
1) What could have been the reason for this patient to develop ataxia in the past 1 year?
ANSWER
CAUSE : ALCOHOLISM 
Mechanism:
                Damage from alcohol is a common  cause of cerebellar ataxia. In patients with alcohol related ataxia, the symptoms affect gait (walking) and lower limbs more than arms and speech. It can also cause associat

2) What was the reason for his IC bleed? Does Alcoholism contribute to bleeding diatheses ?
ANSWER
As per this article , it is evident that the  risk of intracranial bleeding is increased in  chronic alcoholics.


CASE F 
LINK TO PATIENT DETAILS


Questions

1.Does the patient's history of road traffic accident have any role in his present condition?
ANSWER
    No

2.What are warning signs of CVA?
ANSWER
  • Sudden numbness or weakness in arm or leg especially one side of body
  • Sudden onset of dizziness , difficulty in walking
  • Sudden confusion ,trouble speaking or understanding speech
  • Sudden  headache with no known cause

3.What is the drug rationale in CVA?
ANSWER
       Combination of thrombolytic  And neuroprotective therapy is given


4. Does alcohol has any role in his attack?
ANSWER
       As the patient is a chronic alcoholic, it is possible that alcohol migh have not played role in his attack  


5.Does his lipid profile has any role for his attack??
ANSWER
Definitely ,high TGA And high cholesterol are risk factors for stroke 


CASE G
LINK TO PATIENT DETAILS

QUESTIONS

1)What is myelopathy hand ?
ANSWER
                  In many of the cervical spinal cord disorders,the ulnar 2-3 fingers  lose their ability to grasp ,and rapidly release objects  and also there is an impairment of adduction and extension in these fingers. it is called as myelopathy hand.

2)What is finger escape ?
ANSWER
  • It is also called as  WARTENBERG SIGN 
  • It is an involuntary abduction of little finger due to unopposed action of EXTENSOR DIGITI MINIMI
  • DIFFERENTIAL DIAGNOSIS: ULNAR NERVE PALSY, CERVICAL MYELOPATHY
3)What is Hoffman’s reflex?
ANSWER  
 Hoffmanns reflex
            When  The investigator  flicks the fingernail of middle finger  down , there is an involuntary Flexion of thumb or index finger
This is called as positive Hoffman's  reflex 
It is seen in UMN lesions and corticospinal tract lesions.

Reference:


CASE H 
LINK TO PATIENT DETAILS

 QUESTIONS

              
1) What can be the cause of her condition ?  
ANSWER       
                   THROMBOSIS AND INFARCTION

2) What are the risk factors for cortical vein thrombosis?
ANSWER  
  1. BETA THALASSEMIA
  2. HEMOLYTIC ANEMIA
  3. HEAD TRAUMA
  4. IRON DEFICIENCY
  5. CANCER
  6. INTRACRANIAL HYPOTENSION       
3)There was seizure free period in between but again sudden episode of GTCS why?resolved spontaneously why?                           
ANSWER  
         The postictal state is the altered state of consciousness after an epileptic seizure. It usually lasts between 5 and 30 minutes, but sometimes longer in the case of larger or more severe seizures, and is characterised by drowsiness, confusion, nausea, hypertension, headache or migraine, and other disorienting symptoms.

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

3. CARDIOLOGY

  CASE A
  Link to patient details:



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

2.Why haven't we done pericardiocenetis in this pateint?        
ANSWER
        As the condition is resolving, there is not need for pericardiocentesis
             
3.What are the risk factors for development of heart failure in the patient?
ANSWER
  • hypertension
  • CAD
  • DM
  • MEDICATIONS

4.What could be the cause for hypotension in this patient?
ANSWER
            THE VENOUS RETURN IN THIS PATIENT IS LOW ,WHICH IN TURN LEADS TO LOW CARDIAC OUTPUT THEREBY LEADING TO HYPOTENSION 


CASE B

Link to patient details:



Questions:

1.What are the possible causes for heart failure in this patient?
ANSWER
  1. hypertension
  2. alcoholic cardiomyopathy
  3. CKD 
2.what is the reason for anaemia in this case?
ANSWER
*KIDNEYS aare the source of erythropoietin 
*when the kidney is effected erythropoietin is decreased which decreases RBC COUNT thereby leading  to anemia

3.What is the reason for blebs and non healing ulcer in the legs of this patient?
ANSWER
     diabetes mellitus
4. What sequence of stages of diabetes has been noted in this patient?
ANSWER
       stage 1: defined as DCBD (dysglycemia-based chronic disease )insulin resistance;
       stage 2: defined as DCBD prediabetes;
       stage 3: defined as DCBD type 2 diabetes; and
       stage 4: defined as DCBD vascular complications, including retinopathy, nephropathy or                        neuropathy, and/or type 2 diabetes-related microvascular events.
          All these stages have been noted in this case

CASE C
Link to patient details:
 

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?
ANSWER
EVOLUTION OF SYMPTOMATOLOGY 
*HISTORY OF FACIAL PUFFNESS ON AND OFF 2YR 
*HISTORY OF SOB SINCE 2 DAYS GRADE 2---> 4

ANATOMICAL LOCALISATION:  HEART
CONDITION: FIBRILLATION

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


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

Type 1 cardiorenal syndrome occurs when there is acute decompensation of cardiac function leading to a decrease in glomerular filtration. Researchers have previously proposed a decline in cardiac output with decreased renal perfusion as the leading underlying cause for worsening kidney function in cardiorenal syndrome types 1 and 2.  However, recent studies have postulated that increased central venous pressures are a more critical factor. When patients develop fluid overload due to worsening cardiac function, venous pressures increase and are transmitted back to the efferent arterioles; this results in a net decrease in the glomerular filtration pressure and renal injury. Other factors involved in the pathogenesis of types 1 and 2 cardiorenal syndromes include elevated intraabdominal pressures, activation of the renin-angiotensin-aldosterone system (RAAS), activation of the sympathetic nervous syndrome and increased inflammatory damage to the kidney related to heart failure. Targeting this cycle is the mainstay of therapy for type 1 cardiorenal syndrome. Types 3 and 4 cardiorenal syndromes more likely result from volume overload from renal dysfunction, abnormal cardiac function in the setting of metabolic disturbances (such as acidemia), and neurohormonal changes that accompany renal disease. Patients can develop type 5 cardiorenal syndrome in the setting of sepsis, systemic lupus erythematosus (SLE), diabetes mellitus, decompensated cirrhosis, or amyloidosis; all of these disorders can lead to disease in both the heart and kidney.

REFERENCE:  https://www.ncbi.nlm.nih.gov/books/NBK542305/


4) What are the risk factors for atherosclerosis in this patient?
ANSWER
  • abnormal lipid profile
  • DM
  • Hypertension
  • high saturated fats in diet
  • obesity          
5) Why was the patient asked to get those APTT, INR tests for review?
ANSWER
      APTT & INR are the basic tests for clinical evaluation 
APTT is a measure of intrinsic coagulation pathway and is used to know thrombotic activities


CASE D
Link to patient details:



Questions-

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?
ANSWER
67 year old hypertensive and diabetic women with a recent history of completely treated pulmonary tuberculosis has developed sudden onset sweating on exertion and   grade 4 shortness of breath at night.

At the time of presentation she had a higher level of blood sugars of about 256 milligram per deciliter. On examination bilateral inspiratory crepitations were heard.

Anatomical localisation:  coronary artery obstruction.

primary etiology: chrnic hypertension and diabetes

2) What are mechanism of action, indication and efficacy over placebo of each of the pharmacological and non pharmacological interventions used for this patient?
ANSWER
    Placebo has no physiological and pharmacological actions
1.METOPROLOL 
  • It is a beta blocker
  • It is used to control blood pressure ,and also used in Angina and M
3) What are the indications and contraindications for PCI?
ANSWER
Indications
  • Acute STEMI
  • Acute non ST elevation acute coronary syndrome
  • Angina equivalent
  • Stable and unstable angina
  • Critical coronary artery stenosis
Absolute contraindications
  • Non compliance with the procedure and inability to take the dual antiplatelet therapy
  • Multiple percutaneous interventions re stenosis
  • High bleeding risk
Relative contraindications
  • Intolerance for long term antiplatelet therapy
  • Short artery less than 1.5 mm
  • Hypercoagulable state
  • Absence of cardiac surgery backup
  • High grade CKD
  • Chronic  total occlusion of SVG
  • Critical left main artery occlusion with no graft or collateral 
  • Stenosis less than 50%
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?
ANSWER
people suffer complications including bleeding, blood clots, infection, heart rhythm disturbances and even death from heart attack if PCI is performed in a patient who doesnot need it.


References: 


CASE E
Link to patient details:



Questions:

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?
ANSWER
    The patient has first developed right sided chest pain over three days ago which was insidious in onset and gradually progressive type. The pain was radiating to back and there wa

Anatomical localisation: inferior wall of heart 

Primary etiology : long standing DM

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

TAB. ASPIRIN 325 mg PO/STAT:

        It is an NSAID which is used to releive impending MI 

TAB ATORVAS 80mg PO/STAT

      It is a statin which is used in patients with high cholesterol levels 


TAB CLOPITAB 300mg PO/STAT

                            It is an anti platelet medication which is used to prevent MI OR FURTHER DAMAGE

INJ HAI 6U/IV STAT

           It is regular insulin which is used to control blood levels 

VITAL MONITORING.

               It is necessary for constant surveillance of patient .Any abnormality in vitals should be treated immediately


3) Did the secondary PTCA do any good to the patient or was it unnecessary?
ANSWER
    It would be Definitely of help As it restores a proper blood flow in the artery



CASE F
Link to patient details:


QUESTIONS:

1. How did the patient get  relieved from his shortness of breath after i.v fluids administration by rural medical practitioner?
ANSWER 
   As i.v fluids are administered in order to increase the ability of heart to pump blood,it might have relieved the hypotension there by relieving the symptoms


2. What is the rationale of using torsemide in this patient?
ANSWER 
the patient has hypotension and even then torsemide was used. will it not cause severe hypotension ??

3. Was the rationale for administration of ceftriaxone? Was it prophylactic or for the treatment of UTI?
ANSWER
As the patient has dribbling of urine with oliguria and a previous history of TURP they might have suspected UTI and empirically ceftriaxone was given.
4) GASTROENTEROLOGY (AND PULMONOLOGY) 10 Marks

A) Link to patient details:


QUESTIONS: 

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?
ANSWER 
Evolution of symptomatology and event timeline -
  •  Pain abdomen and vomiting ; was treated conservatively 5 YRS AGO 
  •  Pain abdomen and vomiting Since 1 week 
  •  Constipation, burning micturition, fever Since 4 days
After admission - 
  • CT scan - showed pseudocyst
  • Chest X ray - showed left pneumothorax and left pleural effusion
Anatomical location - Pancreas

Primary etiology - Chronic alcohol intake

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?
ANSWER
Amikacin, metronidazole and meropenam are all.given to control infection.

TPN : total parenteral nutrition
    It is given to bed ridden patients.it contains carbohydrates,proteins, fats vitamins and minerals

NS/RL
    It is given as fluid replacement inorder to combat dehydration
 
Tab.Pantop
   It is a proton pump inhibitor.it is used in this case for its anti pancreatic secretory 

Inj.octreotide
    It is a somatostatin analogue
    It decreases the secretions of pancreas
    It also has anti inflammatory and cytoprotective effects
Inj.Thiamine
       It is B1 supplement. 
       It is given here because; due to long fasting & TPN  usage , body may develop B1 deficiency
       Wernicke encephalopathy secondary to B1 deficiency may be caused... so a prophylactic B1 supplemention is necessary.

Inj.TRAMADOL
                     It is an opioid analgesic which is given to relieve pain.

CASE B

LINK TO PATIENT DETAILS:


QUESTIONS:
1) What is causing the patient's dyspnea? How is it related to pancreatitis?
ANSWER
  the patient has pleural effusion which is cause for his dyspnea
pancreatico pleural fistula may be the cause
2) Name possible reasons why the patient has developed a state of hyperglycemia.
ANSWER
  • pancreatitis causing decreased insulinrelease
  • hyperglycemia due to geneal inflammation 
3) What is the reason for his elevated LFTs? Is there a specific marker for Alcoholic Fatty Liver disease?
ANSWER
elevated LFT due to chronic alcoholism
specific markers AST>ALT ,INCREASED GGT
4) What is the line of treatment in this patient?
ANSWER
  •  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 C
 Link to patient details:


Possible Questions :-

1) What is the most probable diagnosis in this patient?
ANSWER
  • ruptured liver abscess
  • intraperitoneal hematoma
  • grade 3 renal parenchymal disease
2) What was the cause of her death?
ANSWER
          death after emergency laparotomy might be due to aspiration?
3) Does her NSAID abuse have  something to do with her condition? How?
 ANSWER
       NSAID may hamper cyto-protective effect of PROSTAGLANDINS which lead to kidney damage
5) Nephrology (and Urology) 10 Marks 

CASE A
 Link to patient details:


1. What could be the reason for his SOB ?
ANSWER
  • TURP SYNDROME           
  • acidosis caused by diuretics 
2. Why does he have intermittent episodes of  drowsiness ?
ANSWER
          HYPONATREMIA caused by diuretics
    
3. Why did he complaint of fleshy mass like passage in his urine?
ANSWER 
        any clots of TURP left in URETHRA OR pus cells in the urine might have appeared as fleshy mass to him.

4. What are the complications of TURP that he may have had?
ANSWER
  • TUR Syndrome
  • clot retention
  • UTI 
  • early urge incontinence 

CASE B 
Link to patient details:



Questions

1.Why is the child excessively hyperactive without much of social etiquettes ?
ANSWER
The child would be suffering from anxiety disorder which leads to this  type of behaviour.

As pointed out in the history sudden stoppage of smartphone exposure must have affected the child psychologically which in turn have led to such a behaviour 

2. Why doesn't the child have the excessive urge of urination at night time ?
ANSWER
      As the patient has no urge of urination at night, he might be suffering from 
  • psychomotor disorder
  • undiagnosed anxiety 
      
3. How would you want to manage the patient to relieve him of his symptoms?
ANSWER
  • antibiotic therapy
  • analgesics
  • suspicion of OAB - anti cholinergic therapy      


6) Infectious Disease (HI virus, Mycobacteria, Gastroenterology, Pulmonology) 10 Marks 

LINK TO PATIENT DETAILS


Questions:

 1.Which clinical history and physical findings are characteristic of tracheo esophageal fistula?
ANSWER
                  The features like dysphagia loss of weight cough while eating aspiration of food would be suggestive of tracheoesophageal fistula which would  then be  confirmed by investigations.

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

prevention : initiate  ART before profound immunosuppression
risk is low in patient with CD4+ greater than 100 at initiation of ART 


7. INFECTIOUS DISEASES AND HEPATOLOGY 

Case A

Link to patient details:




1. Do you think drinking locally made alcohol caused liver abscess in this patient due to predisposing factors
 present in it ? 

What could be the cause in this patient ?
ANSWER
  • alchol consumption is a risk factor for liver damage 
  • therefotre, consumption of a contaminated toddy for 30 yrs would be a potential risk.

2. What is the etiopathogenesis of liver abscess in a chronic alcoholic patient ? ( since 30 years - 1 bottle per day)
ANSWER
                    Alcohol suppresses the function of Kupffer cells in the liver, which has the important role of clearing the amoeba. This leads to pathogenic invasion leading abscess formation

3. Is liver abscess more common in right lobe ?
ANSWER : Yes
4.What are the indications for ultrasound guided aspiration of liver abscess ?
ANSWER
  • A large liver abscesa>5cm in diameter as it woul rupture
  • Multiple liver abscess
  • Liver abscess in left lobe
  • Non responding to medical treatment for >7 days  




 Case B
 Link to patient details:



QUESTIONS:


1) Cause of liver abscess in this patient ?
ANSWER
      Considering the young age of patient involvement of right lobe, and as the abscess
is single ,it would be an amoebic abscess


2) How do you approach this patient ?
ANSWER
*thorough history taking
*clinical examination
*routine investigation
*USG
*MEDICAL TREATMENT
*IF NOT RESOLVED- ASPIRATION 

3) Why do we treat here ; both amoebic and pyogenic liver abscess? 
ANSWER
        As a convention any case of liver abscess ( less than 5 cm diameter and also it should be a single abscess) with a suspected infective etiology is treated for both amoebic and pyogenic abscess in order to avoid risk.

4) Is there a way to confirm the definitive diagnosis in this patient?
ANSWER
         E.IHA is the most rapid test for distinguishing between amoeba and pyogenic abscess.
However in a case of multiple liver abscess and a single liver abscess of >5cm diameter  culture and sensitivity of the aspirate would be of use.



References


8) Infectious disease (Mucormycosis, Ophthalmology, Otorhinolaryngology, Neurology) 10 Marks 

Case A 
Link to patient details:

Questions :
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?
ANSWER
 EVOLUTION OF SYMPTOMATOLOGY 
  • 18TH APR:   Post vaccination fever with chills and rigors
  • 28TH APR:   facial puffiness, generalised weakness and periorbital edema
  • 4TH MAY:     presented to OPD in an altered mental state 
 
ANATOMICAL LOCALISATION : RHINO ORBITO CEREBRAL DISEASE



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?
ANSWER
Placebo has no physiological and pharmacological actions.
Drugs given are 
The proposed drug was inj.liposomal amphotericin B but due to un availability itraconazole is being given 
Itraconazole is an azole group of anti fungal drugs.it is indicated in fungal infections

3) What are the postulated reasons for a sudden apparent rise in the incidence of mucormycosis in India at this point of time?
ANSWER
      Steroid overuse  and usage of industrial oxygen
       Poor hygienic conditions may all contribute to the mucormycosis


9. INFECTIOUS DISEASES- COVID 19

CASE 1 :Covid 19 with co morbidity (Pulmonology/Rheumatology)

LINK TO CASE:  https://nikhilasampathkumar.blogspot.com/2021/05/covid-pneumonia-in-pre-existing-case-of.htmls

QUESTIONS

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

 ANSWER

       https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7737597/

As per this article , the covid infection is more severe and extensive in people with pre existing lung disease

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

ANSWER

        I WAS NOT ABLE TO FIND THE ANSWER

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

ANSWER  : yes

4) Why was she prescribed clexane (enoxaparin)?

ANSWER  

It is a prophylactic measure in order to prevent any coagulation as covid-19 is a hypercoagulable state.


Case 2  Covid 19 with Diabetes 

Link to the patient case report log:

https://nehapradeep99.blogspot.com/2021/05/a-50-year-old-female-with-viral.html

Questions

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?

ANSWER

Her HbA1C is 7.9 which means that she was having raised sugar from long time,it might have been diagnosed while performing routine diagnostic tests.

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

ANSWER

            Diabetes ia a metabolic disease which might significantly influence pathologic processes in body.

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

ANSWER

              D-dimers are the indicator of thrombosis.In severe covid, the pathologic events lead to vichows triad and hence monitoring and carefully evaluating the patients for thrombotic events is necessary.



Case 3  Covid-19 Severe 

Link to the complete case report log:

https://143vibhahegde.blogspot.com/2021/05/covid-in-26-yo-female.html

Questions:

1. Why was this patient given noradrenaline?

ANSWER

the patient suffered kidney failure which lead to persistent  hypotension for which noradrenaline was given 

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

ANSWER

increase in LDH always denotes some sort of damage

here, increased LDH levels was relatable to some sort of damage in his body 

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

ANSWER

BiPAP is a positive pressure system which has failed in this patient and for improving O2 saturation more invasive method which pushes air  directly into lung was needed

Case 4 Covid 19 Mild

 https://gsuhithagnaneswar.blogspot.com/2021/05/29-year-old-male-patient-with-viral.html?m=1

Questions:

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

ANSWER

Yes, as ESR is an important indicator of immunological loss, and as there is an  increased inflammation and immunological dysfunction in COVID, elevated ESR is most likely due to COVID related inflammation. 

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

ANSWER

duration of infection  was very high

SOB was grade 3 

    the above 2 factors were the reason for his hospitalisation

challenges for home isolation

  • inadequate precautions
  • no social distancing
  • no monitoring
  • emotional trauma for family
PROBLEMS WITH HOSPITALIZATION
  • high cost
  • stress to patient
  • risk of infection to visitors
  • over testing

Case 5:Covid 19 and comorbidity (Altered sensorium, azotemia, hypokalemia) 

Link to the case report log: https://anuragreddy72.blogspot.com/2021/05/case-discussion-on-hypokalemic-periodic.html

Questions:

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

ANSWER :  Severe hypoxia

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? 

ANSWER

  • hospital 1 did not test for serum electrolytes
  • hospital no 2 had taken many factors like weakness, tingling and numbness before patient going into coma into consideration, and then serum electrolytes were tested which showed us hypokalemia 

3) How may covid 19 cause coma? 

ANSWER

  • brain is extremely sensitive to hypoxia
  • a mere hypoxia for 5 minutes is a cause for brain death
  • this patient has a very low O2 saturation [20%] which might have lead to coma     

Case 6 :Severe Covid 19 with altered sensorium 

Link to the case report log: https://vijaykumarkasturi.blogspot.com/2021/05/65-years-old-male-with-viral-pneumonia.html

1. What was the cause of his altered sensorium?

ANSWER:

* Alcohol withdrawal

* ICU psychosis

* UREMIC ENCEPHALOPATHY 

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

ANSWER ; CARDIOPULMONARY ARREST is the immediate cause of death


Case 7: Covid 19 Moderate with ICU psychosis 

Link to the case report log: https://drsaranyaroshni.blogspot.com/2021/05/a-67-year-old-lady-in-icu-with-covid.html

Questions :

1.What is the grade of pneumonia in her?

ANSWER : MODERATE 

2.What is the ideal day to start steroids in a patient with mild elevated serum markers for COVID ?

ANSWER: 

* STEROIDS in covid are to combat cytokine storm

therefore, steroids are given before onset of cytokine storm

3.What all could be the factors that led to psychosis in her ?

ANSWER

ICU psychosis

  • continuous monitoring
  • hospital induced stress
  • improper orientation 

4.In what ways shall the two drugs prescribed to her for psychosis help ?

ANSWER:

the 2 drugs given are piracitam and resperidone

piracetam - improvement in mood and memory ,cogntive enhancement

resperidone- decreases dopaminergic and serotonergic interactions

5.What all are the other means to manage such a case of psychosis?

ANSWER

  • correct underlying diseases
  •  good sleep 
  • anti psychotic therapy 

6.What all should the patient and their attendants be careful about ( w.r.t. COVID )after the patient is discharged ?

ANSWER

  • strict isolation for a period of 7 days
  • continuous O2 monitoring -7 days
  • look  for SOB,chest pain, cyanosis and other symptoms 

7.What are the chances that this patient may go into long covid given that her "D Dimer" didn't come down during discharge? 

ANSWER

long covid - increased CRP AND D -DIMERS 

This patient has elevted D -DIMERS at discharge, so she has a potential risk to go into long covid 


Case 8 :Covid 19 Moderate 

Link to the complete case report log :https://bhavaniv.blogspot.com/2021/05/35yrm-with-viral-pneumonia-secondary-to.html?m=1

Questions:

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

ANSWER : NO 

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

ANSWER 

* YES, these drugs aim at reducing immune responese by supressing immue system

*this may actually lead to funagl infections like mucormycosis in a survivor

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

ANSWER : yes

Third risk factor is prolonged ICU stay and duration of mechanical ventilation. While disease severity is closely related to the length of ICU stay, mechanical ventilation poses an additional risk of ventilator-induced lung injury (VILI). Abnormalities of pressure or volume settings underlie this injury leading to a release of proinflammatory modulators, worsening acute lung injury, and increased mortality or pulmonary fibrosis in survivors.

reference: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7654356/

Case 9 :Covid with de novo Diabetes 

Link to Case report log: https://vidya36.blogspot.com/2021/05/a-45-year-old-female-with-viral.html

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

ANSWER: cannot be determined 

2.Could it be steroid induced Diabetes in this patient?

ANSWER: yes 


Case 10 :LComparing two covid patients with variable recovery 

Case report log: https://vidya36.blogspot.com/2021/05/comparative-study.html?m=1


1.What are the known factors driving early recovery in covid?

ANSWER

*young age

*controlled sugars

*asymptomatic infection

*no comorbidities


case:11 Covid moderate with first time detected diabetes:

Link to Case report log :https://rishithareddy30.blogspot.com/2021/05/covid-case-report.html 

Questions-

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? 

ANSWER

PROGNOSIS: prognosis is worsened due to diabtes

covid causes pancreatic damage through ACE2 receptors which may lead to  DENOVO DIABETES 

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

ANSWER

  • insulin is more effective in bringing back the sugar levels.
  • so she was not started on oral drugs 


case -12 :Moderate to severe covid with prolonged hospital stay:

https://93deepanandikonda.blogspot.com/2021/05/42-years-female-patient-with-viral.html

Questions :-

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

ANSWER

ALL OF THE FOLLOWING ARE ABNORMAL IN THIS PATIENT 

  • CRP
  • D-DIMERS
  • LDH
  • ESR
  • SPO2

 CASE 13: Severe covid with first diabetes 

Link to Case report log : https://vignatha45.blogspot.com/2021/05/58-years-female-patient-with-viral.html

QUESTIONS 

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

ANSWER

* GLYCOSYLATION of resceptors esp.ACE2

* this increases the severity of infection and extensive tissue damage

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

ANSWER: yes

reference :  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7313120/

3.What is the cause of death in this case?

ANSWER : cardio-pulmonary arrest 


CASE 14: Long covid with sleep deprivation and ICU psychosis 

Link to Case report log: https://jahnavichatla.blogspot.com/2021/05/covid-case-discussion.html

Questions:

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

 ANSWER : HYPERACTIVE DELIRIUM ?

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

ANSWER

  • STEROIDS
  • CVA IN THE PAST
  • HYPERTENSION

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

 A) Sleep deprivation causing ICU pyschosis  B) ICU psychosis causing sleep deprivation 

ANSWER : B

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

ANSWER : elevated serum markers like CRP and D-Dimers 


 

CASE 15: Moderate Covid with comorbidity (Trunkal obesity and recent hyperglycemia) 

Link to Case report Log:

https://meghanaraomuddada.blogspot.com/2021/05/case-1-2021-42yr-old-male-with-fever.html

QUESTIONS: 

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

 ANSWER: YES

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

ANSWER: MAY BE 

It depends on other risk factors of DM 

As of now glycated Hb is high normal 

It means that patient has high sugars even before the covid infection.

as he is already predisposed to have DM 

THERE IS A HIGH CHANCE OF DEVELOPING DM 

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

 ANSWER:  HYPERGLYCEMIA based on its extent worsens the prognosis.

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

ANSWER

   Acc to..  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7857082/

Basing on the above cited source, the patients with significant rise in glucose must be treated

# those with glucose levels less than 200 mg/dl can use oral hypoglycaemics\

#  severe covid|+high sugars= insulin

5. What is thrombophlebitis fever? 

ANSWER: fever in thrombophlebitis due to inflammatory response

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

ANSWER

STOPPING INFUSION is not needed

DOC: NSAID 



Case16: Mild to moderate covid with hyperglycemia 

LINK TO PATIENT DETAILS:

https://vaishnavimaguluri138.blogspot.com/2021/05/viral-pneumonia-secondary-to-covid-19.html

QUESTIONS: 


1. What could be the possible factors implicated in elevated glycated HB ( HBA1c ) levels in a previously Non-Diabetic covid patient?

ANSWER

COVID 19 is known to cause pancreatic islet cells as it have more receptor expression in endocrine pancreas. this might have led to deficiency of insulin in a previously susceptible patients with impaired glucose tolerance

2. 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?

ANSWER

As the covid 19 infection causes extensive pancreatic damage it may lead to insulin deficiency.Further, insulin resistance is also implicated due to IL-6 ,TNF -alpha etc..,there is a high propensity to cause diabetes in post -COVID state.


3. How is the prognosis in such patients? 

ANSWER

Diabetes is a hypercoaguable state. NEW ONSET DM has more severe effect. There is a higher propensity of thrombotic events via ANTI THROMBIN 3  mediated mechanism.

THIS IS ALL LEADING TO A WORST PROGNOSIS IN THIS PATIENT 

4. Do the alterations in glucose metabolism that occur with a sudden onset in severe Covid-19 persist or remit when the infection resolves?

ANSWER

        it depends upon the patients existing health status.

5) Why didn't we start him on Oral hypoglycemic agents earlier? 

ANSWER

    ANSWER NOT FOUND 

References

1.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7233217/

2.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7765692/


 CASE :17 Covid 19 with hypertension comorbidity 

https://prathyushamulukala666.blogspot.com/2021/05/a-62-year-old-male-patient-with-fever.html

QUESTIONS 

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

ANSWER : 

  • YES, HYPERTENSION IS ASSOCIATED WITH WEAK IMMUNE SYSTEM THEREBY GREATER SEVERITY

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

ANSWER: PNEUMONIA 


CASE :18 Covid 19 with mild hypoalbuminemia 

https://meesumabbas82.blogspot.com/2021/05/a-38-yo-male-with-viral-pneumonia.html

QUESTIONS: 

1. What is the reason for hypoalbuminemia in the patient?

ANSWER

  • DECREASED SYNTHESIS
  • INCREASED METABOLISM 

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

ANSWER

  • It is generally seen in viral infections and therefore can be due to covid  infection 

3. What is the reason for Cardiomegaly?

ANSWER : uncrontrolled hypertension ??

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

ANSWER

  • varicella
  • pityriasis??

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

ANSWER

Covid 19 is a hypercoaguable state. In the later stages of diseases, thrombosis may set in .

D-Dimers are suggestive of thrombotic events


 CASE :20 Covid 19 with first time diabetes 


https://srilekha77.blogspot.com/2021/05/a-48-year-male-with-viral-pneumonia-due.html 


Questions:

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

ANSWER

             There is no clear cut evidence that steroids definitely increase mortality in diabetic covid patients.But due to a potential risk OTHER ALTERNATIVE should be first choice rather than a steroid.

But, when steroids are used ,they must be cautiously used . A patient on oral hypoglycemic drugs must always be shifted to insulin therapy.

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

ANSWER

         

3)Does chronic alcoholism have effect on the out come of Covid infection????

If yes,how??

ANSWER  : https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7255718/

The study conducted above states that alcoholism has no link to severity of covid

References:

1.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7315113/


CASE 21 :Severe Covid with Diabetes 

https://sudhamshireddy.blogspot.com/2021/05/a-65-year-old-female-with-fever.html

Questions-

1. What can be the causes of early progression and aggressive disease(Covid) among diabetics when compared to non diabetics?

ANSWER

        DIABETES is a chronic inflammatory condition which alters our metabolic state and thereby intervening in our body's response to pathogenic organisms.DIABETES SPECIFICALLY TYPE 2, characterised by hyperglycemia and insulin resistance would promote the production of glycosylation end products and  pro inflammatory cytokines. In addition to this, it also promotes the production of adhesive molecules which are a key in tissue inflammation.

                This may be the basic pathogenesis which not only increases the susceptibility of an individual to infections but also increases the severity.

2. In a patient with diabetes and steroid use what treatment regimen would improve the chances of recovery?

ANSWER

  • Glycemic control : with insulin or oral agents 
  • limited usage of steroids 
  • careful monitoring of patient
  • oxygenation if needed

3. What effect does a history of CVA have on COVID prognosis?

ANSWER

  As per the study conducted , there is an increased risk of mortality and morbidity in patients with  prior history of stroke 

 References

1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7144611/

2.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7535872/#:~:text=Patients%20with%20history%20of%20prior,make%20them%20a%20vulnerable%20population.


CASE 23 Covid 19 with multiple comorbidities:

LINK TO PATIENT DETAILS  :https://nehae-logs.blogspot.com/2021/05/case-discussion-on-viral-pneumonia.html

QUESTIONS:

1) What do you think are the factors in this patient that are contributing to his increased severity of symptoms and infection? 

ANSWER

  • Preexisting lung disease inform of tuberculosis and bronchial asthma
  • diabetes mellitus
  • prior attack of pneumonia
  • CKD


2) Can you explain why the D dimer levels are increasing in this patient? 

ANSWER

  • COVID &DM are both hypercoaguable states
  • this might have initiated the thrombosis in the patient which is marked by rise in D-DIMER levels


3) What were the treatment options taken up with falling oxygen saturation?

ANSWER

* Head end elevation

 *Continuous O2 inhalation

 *Intermittent BiPaP

* Bronchodilators

4) 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)

ANSWER

High levels of glucose in the blood leads to accumulation of extra material in glomeruli. It increases the stress of glomeruli in turn leading to gradual and progressive scarring. Eventually leads to the development of CKD


10. MEDICAL EDUCATION

Practical/clinical knowledge is important in medicine.

E-log centric practical learing helped us to be consistent with our studies

This helped me to sharpen my thinking and improve my skill of history taking.

clinical  discussions in various social media plaforms helped us to learn in these uncertain times.

I am grateful for the oppurtunity.


 


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