BIMONTHLY INTERNAL EXAM( JANUARY)
26 year old woman with complaints of altered sensorium somce 1 day,headache since 8 days,fever and vomitings since 4 days
a). What is the problem representation of this patient and what is the anatomical localization for her current problem based on the clinical findings
A) 26 year old female who is a mother of two children, a tailor and agricultural labourer got married 10 yrs back
-
Headache since 8 days- in bitemporal vertex region has been aggrevated since 1 week .
After stopping using steroids she has
-Fever since 4 days- low grade not associated with chills and rigors.
- Vomitings since 1 week (multiple episodes).
She has generalised weakness,decreased apetite and unable to walk for which admitted in nalgonda.
-Neck pain since 4 days
At the time of presentation she has altered sensorium with irrelevant speech since 3 am in the morning
K/c/of SLE since 3 years (Hydrochloroquine-200mg/OD,Sulfasalazine,Methylprednisolone,Alandronic acid and Cholecalciferol,Aceclofenac,Flupirtine,Gabapentine,Methylcobalamin tablets), which she stopped 10 days back.
patient used to get low grade fever and joint pains when she missed her medications.
b) What is the etiology of the current problem and how would you as a member of the treating team arrive at a diagnosis? Please chart out the sequence of events timeline between the manifestations of each of her problems and current outcomes.
A)On admission Na was 120 meq/L . correction was given with 3% Nacl (250ml over 5 hours- approx 125meq )...serum Na rised to 131 meq/L
On correction of sodium pt became c/c/c but had intermittent confusion and altered sensorium
The first on-call team thought it has euvolemic hyponatremia secondary to SIADH
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4016091/
- Development of hyponatremia is associated with various inflammatory diseases including pneumonia, severe acute respiratory distress syndrome, tuberculosis, meningitis, encephalitis, human immunodeficiency virus infection, and malaria
The second on-call team Decided to get MRI for this pt found acute stroke in left thalamus ...Later because of History and usage of Immunosuppressants ..the second on-call team also did CSF analysis which showed Positive for CBNAAT...thus we came to the diagnosis of TB Meningitis
Final diagnosis:Tubercular meningitis with k/c/o SLE since 3 years
3yrs ago diagnosed as SLE and on immumosupressents---->
Intermittent headache since 1 momth----->Fever and vomtings 5 days back-----> altered sensorium since 1 day
On admission : day 1:pt drowsy and not oriented-----> day 2: fever+ oriented intermittently------> Day 3 -----> Sensorium improved and pt was on methylprednisolone and ceftriaxone for 3 days------> pt started on ATT from Day 4 and continued
c) What is the efficacy of each of the drugs listed in her prior treatment plan that she was following since last two years before she stopped it two weeks back?
A) Hydrochloroquine
https://pubmed.ncbi.nlm.nih.gov/29987550/
https://onlinelibrary.wiley.com/doi/full/10.1002/acr2.11084#:~:text=Background,in%20flares%20compared%20with%20placebo.
-Methylprednisolone
https://clinicaltrials.gov/ct2/show/NCT04146220
https://pubmed.ncbi.nlm.nih.gov/12220105/#:~:text=of%20infectious%20complications-,Low%2Ddose%20pulse%20methylprednisolone%20for%20systemic%20lupus%20erythematosus%20flares%20is,Lupus.
d) Please share any reports around similar patients with SLE and TB meningitis?
https://pubmed.ncbi.nlm.nih.gov/10067053/
Q)Any reports of normal csf leukocyte count and normal csf protein in meningitis?
What could be the probable cause for a normal csf leukocyte count in a patient with chronic meningitis?
A)Normal CSF WBC counts can be seen in enteroviral meningitis, particularly in young infants. Normal CSF WBC can also rarely be seen in herpes simplex virus meningoencephalitis early in the course of infection
e) What is the sensitivity and specificity of ANA in the diagnosis of SLE?
Wichainun R, Kasitanon N, Wangkaew S, Hongsongkiat S, Sukitawut W, Louthrenoo W. Sensitivity and specificity of ANA and anti-dsDNA in the diagnosis of systemic lupus erythematosus: a comparison using control sera obtained from healthy individuals and patients with multiple medical problems. Asian Pac J Allergy Immunol. 2013 Dec;31(4):292-8.
Question 2:
https://youtu.be/sw8o8y5Yw_I
Q)What was the researcher's hypothesis?
A) low magnesium levels leading to rapid profession and poorer outcome in diabetic patients
Q)What is the current available evidence for magnesium deficiency leading to poorer outcomes in patients with diabetes?
A)Magnesium deficiency can lead to development of complications such as retinopathy, nphropathy, thrombosis and hypertension.
https://www.google.com/url?sa=t&source=web&rct=j&url=https://www.medresearch.in/index.php/IJMRR/article/view/336/1394%23:~:text%3DType%25202%2520diabetes.-,Magnesium%2520deficiency%2520can%2520lead%2520to%2520development%2520of%2520complications%2520such%2520as,when%2520compared%2520to%2520healthy%2520controls.&ved=2ahUKEwjNmfrC7KDuAhXVYisKHdqICDUQFjABegQIAhAE&usg=AOvVaw0SYe5MLVOJBuOEsSFcwSZA
Question 3:
Q)What was the research question in the above thesis presentation?
A) Will salt restriction will effect decrease or contol of bp in hypertensive patients
Will 24 hrs sodium excretion will be same as amount of sodium intake
Q)What was the researcher's hypothesis?
A) The individuals with salt sensitivity will be more prone to increase in either systole or diastole in hypertensive patients
Q)What is the current available evidence for the utility of monitoring salt excretion in the hypertensive population?
A)https://www.google.com/url?sa=t&source=web&rct=j&url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6419439/&ved=2ahUKEwiC9MvY4aTuAhXUTX0KHe1oCCgQFjAAegQIAhAB&usg=AOvVaw0rW4q7bHJpoHxjcxg6gsOT&cshid=1610948506258
3) Please critically appraise the full text article linked below:
https://onlinelibrary.wiley.com/doi/full/10.1111/j.1365-2796.2003.01233.x
What is the efficacy of aspirin in stroke in your assessment of the evidence provided in the article. Please go through the RCT CASP checklist here https://casp-uk.net/casp-tools-checklists/ and answer the questions mentioned in the checklist in relation to your article.
4) Learning experiences from month of January
1 st Jan : Posted in Nephrology mrng duty
Done rounds in icu ward and dialysis room
Done arogyasree works
2 nd Jan :. Mrng nephro duty
Rounds in icu ward and dialysis room
Done discharges
Learned differencea between proximal and distal RTA
Done RT - pcr to two patients
Referral seen in post op ward in view of pedal odemal and rearranged RFT
3 rd jan : placed central line
Rounds in ward icu and dialysis room
Discussion with faculty and unit regarding to take the patient of 63 female to take for dialysis or not
4 th jan: Nyt duty Nephrology
Managed the pt of CKD on mHD with fever and loose stools
5 nd Jan: elderly female with decreased urine output and pedal edema .- AKI On CKD with urosepsis .
Discussion on AKI on CKD pt whether to do dialysis or not
6th Jan: central line to one of the ckd patients , and took hemodialysis for him.
Elderly female took for dialysis as well.
7 th jan: Nephrology nyt duty
Managed the CKD pt with uncontrolled sugars with insulin infusion 40 IU in 39 ml Ns @ 6 ml /hr
8th Jan: Ckd (? Diabetic nephropathy/Nsaid induced )
Took an ecg now - showing incomplete rbbb.
Bp - 160/100
pr - 76bpm
cvs - s1s2 present ; RS - B/L fine crepts present.
2 sessions of hemodialysis done
Monitored the above patient in view of any silent MI
9 th jan: learned 2D echo on young man with heart failure
He was having Dilated RA,RV,LA with normal EF. so a diagnosis of HFPEF was made. (? Wet beri beri.)
10th Jan:sunday
11 th jan- Have morning shift from 8am -6pm this week.
Attended morning rounds in Icu and amc with Dr ramulu sir
Aki on ckd pt Sob increased since sunday evening , tachycardia and saturation was not maintaining.
Her cxr showed bilateral infiltrates .
Intially thought of cardiogenic pulmonary edema and increased her diuretic dosages and put her on CPAP.
12 th jan: Elderly female with AKI on Ckd wasnt improving with dialysis and diuretics ,so suspected a non cardiogenic pulmonary edema in her - ? Covid 19 / ? TRALI.
TRALI was suspected as she had one unit of PRBC transfused during her dialysis session on Saturday night , she developed sob from Sunday evening , which increased later and wasnt subsiding with dialysis and diuretics.
13 th jan: CKD on MhD pt who got intubated previous night in view of respiratory distress and severe metabolic acidosis.
-Changed pt settings to ACMV VC mode with adequate sedation,as pt cxr was showing bilateral infiltrates and he was not able to take enough tidal volume.
14 th jan: The ventilator pt , tapered sedation.Pt was still drowsy and started him on inotropes for low blood pressure.
Took one session of hemodialysis for 4 hrs eith UF of one litre and carefully monitoring his blood pressure .
Aki on ckd - Took one session of hemodialysis for her with intermittent CPAP.
15th Jan:Ventilator pt was still drowsy ,with low blood pressure . Me and Dr vaishnavi mam placed a Triple lumen catheter for him for giving medications ,as peripheral lines couldn't be placed due to generalized odema.
- AKI ON CKD pt starting feeling better ,her sats improved and in cxr infiltrates reduced.
16 th jan:AKI ON CKD pt improved.Planned for one more session of hemodialysis for her.
CKD on MHD case who was on ventilator was shifted to T PIECE early morning. Pt sensorium improved . So was planning to extubate him evening.
Successfully extubated the patient around 4pm . Sats were maintaining . Although due to laryngeal edema ,pt was having grunting . But abg did not show respiratory failure. So gave him IV HYDROCORTISONE AND started him on nebulization with budecort and duolin and chest physiotherapy was given adequatel
https://vamsikrishna1996.blogspot.com/2021/01/36-year-male-presented-to-casualty-at.html?m=1
5) a) What are the possible reasons for the 36 year old man's hypertension and CAD described in the link below since three years?
A)Patient is chronic smoker might be the risk of CAD
Causes for MI in young
https://www.google.com/url?sa=t&source=web&rct=j&url=https://pmj.bmj.com/content/81/962/741&ved=2ahUKEwi_95rQoKfuAhXIlEsFHUylC2cQFjAFegQIFBAC&usg=AOvVaw0_Dieok_c4acyrUNrlzy0r
b) Please describe the ECG changes and correlate them with the patient's current diagnosis.
A) A) ECG shows evolving myocardial infarction changes with progressive ST T changes and VPCs
Vpc is followed by a compensatory pause.
Rate - 75
Rythm - Intial ecgs rate is Irregular with Vpc ,later becoming regular
Axis - Normal
St - elevations in v1-v4 ,about 2mm and increasing( (Anter septal MI ).
QS complexes in v1-v. Indicating previous AWMI.
No LVH.
and echo showing hypokinetic segment in LAD territory (? LV aneurysm) that may also reflect his past LAD infarct.
c) Share an RCT that provides evidence for the efficacy of primary PTCA in acute myocardial infarction over medical management. Describe the efficacy in a PICO format
A)Primary percutaneous transluminal coronary angioplasty (PTCA) over systemic thrombolysis for the treatment of acute myocardial infarction (AMI). Primary PTCA has shown clinical benefit over thrombolytic therapy in two randomized studies .In the GUSTO IIb study, the mortality of patients assigned to primary PTCA was not statistically different from patients assigned to tissue plasminogen activator (t-PA), although the patients treated by primary PTCA experienced a modest benefit in the combined endpoint of death, nonfatal reinfarction and disabling stroke.
Two-hundred and twenty patients with anterior AMI were randomly assigned in our institution to primary angioplasty (109 patients) or systemic thrombolysis with accelerated t-PA (111 patients) within the first five hours from the onset of symptoms.
A)https://www.sciencedirect.com/science/article/pii/S0735109798006445
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