General Medicine assignment for the month of May

G. Sai Manogna

Roll No:33

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 the link of the questions asked regarding the cases:

http://medicinedepartment.blogspot.com/2021/05/online-blended-bimonthly-assignment.html?m=1

1) Pulmonology (10 Marks) 

A) Link to patient details:

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

Ans:

History

        a]few years back that is almost 20 years back-shortness of breath was seen as this is the 1st episode

in the month of january .that was releveied  by taking medication and it was lasted about one week during working in the paddy feilds .[this continued about seven years in the same period]

12 years ago she had shortness of breath which has lasted about 20 days and continued same pattern for 30days. 

 Latest episode; it lasts for about 30 days and it does not releive by medication.

Other sympyoms; amnesia - 5 yrs ago,generalised weakness [one month ago], Hypotension,Pitting type pedal edema and facial puffiness.

ANATOMICAL LOCALISATION OF PROBLEM;

        bronchi and bronchioles of the lung 

PRIMARY ETIOLOGY;  

                      The symptoms are probably due to the inhalation of paddy dust,and ongoing causative exposure,and abnormal inflamatory responce of the lung.

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

Ans:

1] Head and elevation;  It improves end expiratory lung  volumes.and also shown to improve the oxygenattion  and hypodynemic performance.

        2] B2.Bipap intermittent: By having a custom air pressure for when you inhale and a second custom air pressure when you exhale, the machine is able to provide relief to your overworked lungs and chest wall muscles.

3.inj.Augmentin 

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

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

4. Tab Azithromycin antibiotic

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

5. Inj lasix 

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

6.Tab pantop

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

7.Inj.Hydrocortisone 

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

8.Nebuliser with 

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

B)budecort: It is a corticosteroid and acts as an anti-asthmatic agent. It helps in controlling daily symptoms such as shortness of breath, wheezing and chest pain and prevents the worsening of these symptoms. Budecort should always be administered with the help of nebulisers. Nebuliser is a machine that forms a mist of medicine so that it can reach the lungs2.Bipap intermittent: By having a custom air pressure for when you inhale and a second custom air pressure when you exhale, the machine is able to provide relief to your overworked lungs and chest wall muscles.

3.inj.Augmentin 

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

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

4. Tab Azithromycin antibiotic

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

5. Inj lasix 

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

6.Tab pantop

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

7.Inj.Hydrocortisone 

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

8.Nebuliser with 

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

B)budecort: It is a corticosteroid and acts as an anti-asthmatic agent. It helps in controlling daily symptoms such as shortness of breath, wheezing and chest pain and prevents the worsening of these symptoms. Budecort should always be administered with the help of nebulisers. Nebuliser is a machine that forms a mist of medicine so that it can reach the lungs

9. Chest physcio therapy

10. GRBS 6hrly

11. vitals charting 

12; inj thiamine ;to treat or prevent thiamine insufficiancy.

13. O2 inhalation 

It is used to 

A) manage the condition of hypoxia

B)maintain o2 tension in blood plasma

C)increase oxy haemoglobin in RBC

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

E)reduce the risk of complication 

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

Ans: respiratory infectiionbeing responcibleb for the approx half of the COPD exacerbations.as the infection by allergens

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

Ans:

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

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

Ans: 

Activatyion of the renin angiotensin -aldosterone system and appropriately elevated vplasma arginine vasopressin in COPD may aggrevate the Electrolyte imbalance  durind active accerbation of COPD.

2) Neurology (10 Marks) 

A) Link to patient details:

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

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?

Ans:

as the patient is chronic alchoholic,he drinks about 3-4 quarters  per day. 

 Evolution of symptomology; 

                                            1 year ago-2 to 3 episodes of seizures

4 months ago-Following cessation of alcohol he developed seizures probably GTCS

9 days back-The patient started talking and laughing to himself 

withdrawal seizures are triggered by neuronal networks in the brainstem, including the inferior colliculus.

Ethanol is the primary alcohol ingested by chronic users. It is a central nervous system (CNS) depressant that the body becomes reliant on with extended exposure to ethanol.  It does this by inhibiting the excitatory portion (glutamate receptors) of the CNS and enhancing the inhibitory portions (GABA receptors) of the CNS. When the depressant is stopped, the central nervous system becomes overexcited as the inhibition is taken away. Thus, the body gets an excitatory overload, which results in the symptoms of withdrawal. 

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

Ans:

as the aim of lowering the alcohol levels and its metabolites ,its neuro deppresive effects 

and making patients spnding less in the ED

THIAMINE - 

                mechanism of action ;combines with adenisine tri phosphate in the liver. and it has no effect onthe symptoms and signs of the alcohol withdrawl .or  on the incidence of the seizuers . routine use of the thiamine is recomended  because the development of Wernicke encephalopathy or Wernicke-Korsakoff syndrome is disastrous in these patients and can remain unrecognized. Because orally administered thiamine may have poor enteral absorption in individuals with alcoholism, high-risk patients should receive parenteral thiamine at 100-250 mg once daily for several days. 

LORAZEPAM;  it was by the rehab facilities across the nations to help patients overcome the AUD

                As the mechanism of action it binds to the benzodizepam receptors on the post synaptic GABA  ligand gated channels.

     the indications are active seizures ,severe anxiety.

 Efficacy; it is used to treat all the seizuers 

              PREGABALIN; It was the high α2δ voltage gated channel subunit ligand and acounting for there actions invivo to reduce neuronal excitability and seizures

Potchlor Potklor 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?

Ans:

Due to the excess thalamine deficiency and excess toxins accumalation and due to renal disease caused by excess alcohol addiction.

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

Ans:

chronic alcohol cosumption causes thalamine deficiency due to impaired absorbstion of thalamine from the intestine A  number of mechanisms may be involved in the pathogenesis of thiamin deficiency in the alcoholic population. An important cause is inadequate intake of thiamin. Moreover, there may be decreased conversation of thiamine to the active coenzyme, reduced hepatic storage of the vitamin in patients with fatty metamorphosis, ethanol inhibition of intestinal thiamine transport, and impaired thiamine absorption secondary to other states of nutritional deficiency

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

Ans:

 Mechanical ventilation was an important treatment for patients with AECOPD.13 On the contrary, mechanical ventilation was also an independent risk factor for AKI. 

6). What is the probable cause for the normocytic anemia?

Ans:

Anemia of chronic disease (ACD) is probably the most common type of anemia associated with COPD. ACD is driven by COPD-mediated systemic inflammation. Anemia in COPD is associated with greater healthcare resource utilization, impaired quality of life, decreased survival, and a greater likelihood of hospitalization. Anemia was normocytic and normochromic in nature. The exact cause of anemia of chronic disease may vary. Anemia can be caused by a slight shortening of normal red blood cell survival. the production of red blood cells (erythropoiesis) or erythropoietin (a hormone that stimulates red blood cell production) may be impaired. 

7) Could chronic alcoholism have aggravated the foot ulcer formation? If yes, how and why?

Ans:

Oxygen is important for cell metabolism and is critical for all wound-healing processes Inhibits wound healing by reducing the quantity and quality of oxygen to the wound site.

B) Link to patient details:

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

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?

Ans:

7 days back- Giddiness and 1 episode of vomiting

Asymptotic for 3 days

4 days back-Giddiness (sudden continuous and gradually progressive)

Bilateral hearing loss with aural fullness and tinnitus

Vomitings 2-3 episodes per day(non projectile non bilious with food particles 

Postural instability Unable to walk without support and is swaying with tendency to fall while walking 

Anatomical localisation

Cerebellum which is responsible for postural stability ,ocular movements and vertigo(central)

usually results from damage to the part of your brain that controls muscle coordination (cerebellum). conditions can cause ataxia, including alcohol misuse, certain medication, stroke, tumor, cerebral palsy, brain degeneration and multiple sclerosis.

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

Ans:

Vertin Tablet is employed to stop and treat a disorder of the internal ear referred to as disease. The symptoms include dizziness (vertigo), ringing within the ears (tinnitus), and loss of hearing, probably caused by fluid within the ear. This medicine helps relieve the symptoms by reducing the number of fluid.

Zofer anti-emetics' primarily utilized in the prevention of vomiting (being sick) and nausea (feeling sick) that typically occur after cancer chemotherapy, radiation treatment or surgery.
Ecosporin commonly used for the diagnosis or treatment of Headache, migraine, fever, pharyngitis, neuralgia
Atorvostatin
Statins are effective in reducing both first-ever and recurrent stroke, and this effect seems driven by the extent of LDL-C lowering

Clopidogrel could be a variety of medicine called an antiplatelet: it reduces the danger of blood clots forming within your vascular system or blood vessels.

Mvt Methylcobalamin is employed in cyanocobalamin deficiency.

Methylcobalamin could be a kind of vitamin B that restores its level within the body thereby helping in treating certain anemias and nerve problems.

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

Ans:

Raised blood pressure (BP) is common after stroke but its causes, effects, and management still remain uncertain.It exists in more than three quarters of patients, of which about half have a history of hypertension [1], and it declines spontaneously in two-thirds of cases returning to prestroke levels over the first week. Its decrease usually occurs 4–10 days after stroke, but in a significant percentage of patients it falls by about 25–30% just within the first 24 hours; particularly when they are moved to a quiet room, they are allowed to rest and their bladder is  empty

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

Ans:

Yes, Atrial fibrillation and alcohol Drinking excessive amounts of alcohol can trigger atrial fibrillation – a type of irregulaR  heartbeat. Atrial fibrillation increases your risk of stroke by five times, because it can cause blood clots to form in the heart. If these clots move up into the brain, it can lead to stroke.   

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?

Ans:

10 years back-Paralysis of both upper and lower limbs bilateral 1 year back-Right anD left paresis due to hypokalemia8 months backSwelling over legs 7 months back - blood infection 2 months back- neck pain6 days back- pain along left upper limb5 days back- chest pain, Difficulty in breathing and was able to feel her own heart bAnatomical localization: Cervical spinE degenerative changes that occur in the cervical spine with age.Dehydrated disks. Disks act like cushions between the vertebrae of your spine. By the age of 40, most people's spinal disks begin drying out and shrinking, which allows more bone-on-bone contact between the vertebrae.Bone spurs. Disk degeneration often results in the spine producing extra amounts of bone in a misguided effort to strengthen the spine. These bone spurs can sometimes pinch the spinal cord and nerve roots.Herniated disks. Age also affects the exterior of your spinal disks. Cracks often appear, leading to bulging (herniated) disks — which sometimes can press on the spinal cord and nerve roots.Stiff ligaments. Ligaments are cords of tissue that connect bone to bone. Spinal ligaments can stiffen with age, making your neck less flexible.

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

Ans:

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

Risk factors  

Female [1] 

[2]Medications like diureticsHeart failure

HypertensionLow BMI [3]Eating disorder and alcoholism: low intake of potassiumDiarrhea, cushing syndrome, 

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

Ans:

ECG changes include flattening and inversion of T waves in mild hypokalemia, followed by Q-T interval prolongation, visible U wave and mild ST depression4 in more severe hypokalemia. Severe hypokalemia can also result in arrhythmias such as Torsades de points and ventricular tachycardia.

Associated symptoms: 

Weakness and fatigue (most common)

Muscle cramps and pain (severe cases)

Worsening diabetes control or polyuria.

Palpitations.

Psychological symptoms 

D) Link to patient details:

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

QUESTIONS:

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

Ans:

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

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

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

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

Ans:

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

E) Link to patient details:

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

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

Ans:

The patient has minor unattended head injuries in the past 1 yr. According to the CT scan, the patient has cerebral haemorrhage in the frontal lobe causing probably for the occurrence of Frontal love ataxia

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

Ans:

The patient has minor unattended head injuries. During the course of time the minor hemorrhages if present should have been cured on their own. But the patient is a chronic alcoholic. This might have hindered the process of healing or might have stopped the healing rendering it to grow further more into 13 mm sized hemorrhages occupying Frontal Parietal and Temporal lobes

F) Link to patient details:

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

Questions

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

Ans:

The closeness of facial bones to the cranium would suggest that there are chances of cranial injuries. Since the Zygomatic arch and Mandibular process is very close to the cranium, this might play a role in the patient's present condition

2.What are warning signs of CVA?

Ans:

Weakness or numbness of the face, arm or leg, usually on one side of the body

Trouble speaking or understanding

Problems with vision, such as dimness or loss of vision in one or both eyes

Dizziness or problems with balance or coordination

Problems with movement or walking

Fainting or seizure

Severe headaches with no known cause, especially if they happen suddenly

3.What is the drug rationale in CVA?

Ans:

Mannitol- Because of its osmotic effect, mannitol is assumed to decrease cerebral edema. Mannitol might improve cerebral perfusion by decreasing viscosity, and as a free-radical scavenger, it might act as a neuroprotectant. 

Ecospirin 

For the prevention of heart attack, stroke, heart conditions such as stable or unstable angina (chest pain) due to a blood clot.

Atrovas-Atorva 40 Tablet belongs to a group of medicines called statins. It is used to lower cholesterol and to reduce the risk of heart diseases. Cholesterol is a fatty substance that builds up in your blood vessels and causes narrowing, which may lead to a heart attack or stroke.

Rt feed RT feed is a nursing procedure to provide nutrition to those people who are either unable to obtain nutrition by mouth or are not in a state to swallow the food safely. 

4. Does alcohol has any role in his attack?

Ans:

When the patient met with an accident there might be cranial damage which was unnoticed.

If so his occasional drinking may or may not have hindered the process of the minor hemorrhages getting healed and might have caused this condition

But since the patient is not a chronic alcoholic and so Alcohol might not have played any role.

Therefore it cannot be evaluated without further details

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

Ans:

The inverse relationship between serum HDL-C and stroke risk . When taken together it seems clear that higher baseline levels of serum HDL-C lower the risk of subsequent ischemic stroke.

G) Link to patient details:

https://amishajaiswal03eloggm.blogspot.com/2021/05/a-50-year-old-patient-with-cervical.html

__*Questions*_

1)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. 

2)What is finger escape ?

Ans:

Finger escape

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

3)What is Hoffman’s reflex?

Ans: 

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

H) Link to patient details:

https://neerajareddysingur.blogspot.com/2021/05/general-medicine-case-discussion.html?m=1                  

  

Possible questions: 

              

1) What can be  the cause of her condition ?   

Ans:  According to MRI  cortical vein thrombosis might be the cause of her seizures.

                                      

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

Ans: 

Infections:

Meningitis, otitis,mastoiditis

Prothrombotic states:

Pregnancy, puerperium,antithrombin deficiency proteinc and protein s deficiency,Hormone replacement therapy.

Mechanical:

Head trauma,lumbar puncture

Inflammatory:

SLE,sarcoidosis,Inflammatory bowel disease. 

Malignancy.

Dehydration 

Nephrotic syndrome 

Drugs:

Oral contraceptives,steroids,Inhibitors of angiogenesis

Chemotherapy:Cyclosporine and l asparginase

Hematological:

Myeloproliferative Malignancies

Primary and secondary polycythemia

Intracranial :

Dural fistula, 

 venous anomalies 

Vasculitis:

Behcets disease wegeners granulomatosis

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

Ans: 

Seizures are resolved and seizure free period got achieved after medical intervention but sudden episode of seizure was may be due to any persistence of excitable foci by abnormal firing of neurons.                         

             

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

Ans: 

Anticoagulants are used for the prevention of harmful blood clots.

Clexane  ( enoxaparin)  low molecular weight heparin binds and potentiates antithrombin three a serine protease Inhibitor  to form complex and irreversibly inactivates factor xa.

3) Cardiology (10 Marks) 

A) Link to patient details:

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

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

Ans: 

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

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

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

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

Ans:

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

             

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

Ans:

Risk factors for development of heart faliure in this patent

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

high blood pressure

Smoking

Diabetes

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

wosening of pericardial effusion leaing to cardiac tamponade.

4.What could be the cause for hypotension in this patient?

Ans:

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

(May be secondary to TB)

B) Link to patient details:

https://muskaangoyal.blogspot.com/2021/05/a-73-year-old-male-patient-with-pedal.html. 

Questions:

1.What are the possible causes for heart failure in this patient?

Ans:

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

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

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

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

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

 

2.what is the reason for anaemia in this case?

Ans:

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

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

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

3.What is the reason for blebs and non healing ulcer in the legs of this patient?

Ans:

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

4. What sequence of stages of diabetes has been noted in this patient?

Ans:

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

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

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

C) Link to patient details:

 

https://preityarlagadda.blogspot.com/2021/05/biatrial-thrombus-in-52yr-old-male.html

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?

Ans: 

The anatomical site is BLOOD VESSELS;

* ETIOLOGY: 

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

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

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

Ans:

PHARMACOLOGICAL INTERVENTIONS

1. TAB. Dytor

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

2. TAB. Acitrom 

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

3. TAB. Cardivas 

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

4. INJ. HAI S/C

MECHANISM:Regulates glucose metabolism

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

5.TAB. Digoxin 

mechanism:

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

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

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

6. Hypoglycemia symptoms explained

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

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

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

Ans: 

cardiorenal syndrome type 4 is seen in this patient.

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

Ans: 

effect of hypertention

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

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

Ans:

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

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

D) Link to patient details:

https://daddalavineeshachowdary.blogspot.com/2021/05/67-year-old-patient-with-acute-coronary.html?m=1

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?

Ans:

Evolution of symptomatology

           12 years ago- DM2

           1year back Heart burn like episodes(relieved without medication)

           7 months back pulmonary TB (completed the course one month back)

            6 months back Hypertension

           1/2 hour ago- SOB

  Anatomical localisation: Heart muscle 

Primary etiology

   Coronary artery disease:involves the reduction of blood flow to the heart muscle due to build-up of plaque (atherosclerosis) in the arteries of the heart

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

Ans:

Met XL 25 tablet is used to lower the raised blood pressure and various other heart-related conditions such as angina (chest pain), heart failure, preventing further complications.

        Glimiprime M 2 Forte Tablet is a combination of two medicines: Glimepiride and Metformin. This medicine is used in the treatment of type 2 diabetes mellitus (DM). It improves blood glucose levels in adults when taken along with proper diet and regular exercise

      Telma 20 tablet is an antihypertensive medicine that is used to treat high blood pressure and can also help in reducing other heart problems  It acts by relaxing the blood vessels and leads to lower blood pressure

3) 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.

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?

Ans:

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.

associated with substantial morbidity and mortality given the large amount of subtended myocardium at risk

E) Link to patient details:

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

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?

Ans:

Evolution of symptomatology:

       Uncontrolled DM2 since 8 years

     3 days back Mild chest pain dragging type and retrosternal pain(radiated)

     Anatomical localisation: Inferior wall of heart

    Primary etiology: Diabetes type 2 (uncontrolled)

                        high blood glucose from diabetes can damage your blood vessels and the nerves that control your heart and blood vessels

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

Ans:

TAB. ASPIRIN 325 mg PO/STAT

         Mechanism of action: The acetyl group of acetylsalicylic acid binds with a serine residue of the cyclooxygenase-1 (COX-1) enzyme, leading to irreversible inhibition. This prevents the production of pain-causing prostaglandins.

        TAB ATORVAS 80mg PO/STAT

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

        TAB CLOPIBB 300mg PO/STAT

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

       INJ HAI 6U/IV STAT

     VITAL MONITORING.

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

Ans:

 Repeat PTCA provides a valuable, safe and cost-effective way of management for recurrence of stenosis after initially successful angioplasty. It increased the percent of patients with documented long-term success of angioplasty

Over testing and over treatment can raise a person’s risk of cardiovascular death by as much as four times.

F) Link to patient details:

https://kattekolasathwik.blogspot.com/2021/05/a-case-of-cardiogenic-shock.h

1. 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 occurred to the patient

there is decreased preload- so, SOB occurred due to decreased CO

IV fluids administered- there is increased preload- SOB decreased due to better of cardiac output.

2. What is the rationale of using torsemide in this patient?

Ans:

Torsemide used to relieve abdominal distension.

3. Was the rationale for administration of ceftriaxone? Was it prophylactic or for the treatment of UTI?

Ans:

IT IS THE TREATMENT FOR UTI

 Rationale- Used for any bacterial infection.

4) Gastroenterology (& Pulmonology) 10 Marks

A) Link to patient details:

https://63konakanchihyndavi.blogspot.com/2021/05/case-discussion-on-pancreatitis-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?

Ans:

Evolution of symptomatology 

H5 years back-1st episode of pain abdomen and vomitings 

Stopped taking alcohol for 3 years

1 year back 5 to 6 episodes of pain abdomen and vomitings after starting to drink alcohol again 

20 days back increased consumption of toddy intake

Since 1 week pain abdomen and vomiting

Since 4 days fever constipation and burning micturition

Anatomical localisation: Pancreas and left lung

Alcohol and its metabolites produce changes in the acinar cells, which may promote premature intracellular digestive enzyme activation thereby predisposing the gland to autodigestive injury. Pancreatic stellate cells (PSCs) are activated directly by alcohol and its metabolites and also by cytokines and growth factors released during alcohol-induced pancreatic necroinflammation. Activated PSCs are the key cells responsible for producing the fibrosis of alcoholic chronic pancreatitis

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?

Ans:

Non pharmacological interventions : drains ( malecot & icd ),

Even i as a treating physician will follow the same approach

 

B) Link to patient details:

https://nehae-logs.blogspot.com/2021/05/case-discussion-on-25-year-old-male.html

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

Ans:

Pleural effusion might be the cause of patients dyspnea.

        Presence of pleural effusion is currently considered an indication of severe pancreatitis and not just a marker of the disease[24]. Pancreatic ascites and pleural effusion are rare complications of both chronic and acute pancreatitis, and are associated with a mortality rate of 20% to 30%.

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

Ans:

Hyperglucagonemia secondary to stress could be the result of patient developing hyperglycemia.

       Elevated levels of catecholamines and cortisol.

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

Ans:

Elevated liver enzymes are a sign that a person has an inflamed or a damaged liver. Many conditions may cause liver inflammation or damage. In this case the probable reason may be due to liver injury. Alanine aminotransferace (ALT) and Asparate aminotransferase (AST) are the specific markers for alcoholic fatty liver disease. Glutamyl transpeptidase (GGT) is another marker of liver injury, and this enzyme is elevated in people who consumes alcohol. Of all the enzyme markers GGT is the most sensitive biomarker of alcohol consumption.

 

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

Ans:

 IVF: 125 ml/hr

       Inj. PAN 40mg i.v.

       Inj Zofer 4mg i.v.

        Inj. Tramadol 1amp in 100ml i.v.

       Tab. Dolo 650mg

       GRBS charting 6th hourly

      BP charting 8th hourly.

 

C) Link to patient details:

https://chennabhavana.blogspot.com/2021/05/general-medicine-case-discussion-1.html

Possible Questions :-

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

Ans:

àDifferential Diagnosis:

·        *Ruptured Liver Abscess.

·        *Organized collection secondary to Hollow viscous Perforation.

·        *Organized Intraperitoneal Hematoma.

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

·        *Grade 3 RPD of right Kidney

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

2) What was the cause of her death?

Ans:

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

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

Ans:

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

5) Nephrology (and Urology) 10 Marks 

A) Link to patient details:

https://kavyasamudrala.blogspot.com/2021/05/medicine-case-discussion-this-is-online.html

1. What could be the reason for his SOB ?

Ans:

His sob is due to Acidosis which was caused by Diuretics

2. Why does he have intermittent episodes of  drowsiness ?

Ans:

His sob is due to Acidosis which was caused by Diuretics

3. Why did he complaint of fleshy mass like passage in his urine?

Ans:

plenty of pus cells in his urine passage  appeared asfleshy mass like passage to him

4. What are the complications of TURP that he may have had?

Ans:

Difficulty micturition

 Electrolyte imbalances 

 Infection

B) Link to patient details:

https://drsaranyaroshni.blogspot.com/2021/05/an-eight-year-old-with-frequent.html

Questions

1.Why is the child excessively hyperactive without much of social etiquettes ?

Ans: 

Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterized by inattention, or excessive activity and impulsivity, which are otherwise not appropriate for a person's age

For a diagnosis, the symptoms have to be present for more than six months, and cause problems in at least two settings (such as school, home, work, or recreational activities).

2. Why doesn't the child have the excessive urge of urination at night time ?

Ans:

Since the child doesn’t have excessive urge of urination at night but at day there might be a psychiatry related condition 

1. Psychosomatic disorder

2. Undiagnosed anxiety disorder 

3. How would you want to manage the patient to relieve him of his symptoms?

Ans:

Bacterial kidney infection, the typical course of treatment is antibiotic and painkiller therapy.

If the cause is an overactive bladder, a medication known as an anticholinergic may be used. These prevent abnormal involuntary detrusor muscle contractions from occurring in the wall of the bladder

To treat attention deficit hyperactivity disorder:

For children 6 years of age and older, the recommendations include medication and behavior therapy together — parent training in behavior management for children up to age 12 and other types of behavior therapy and training for adolescents.  Schools can be part of the treatment as well. 

Methylphenidate A stimulant and a medication used to treat Attention Deficit Hyperactivity Disorder. It can make you feel very ‘up’, awake, excited, alert and energised, but they can also make you feel agitated and aggressive. They may also stop you from feeling hungry.

Amphetamine belongs to a class of drugs known as stimulants. It can help increase your ability to pay attention, stay focused on an activity, and control behavior problems. It may also help you to organize your tasks and improve listening skills.

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

A) Link to patient details:

https://vyshnavikonakalla.blogspot.com/2021/05/a-40-year-old-lady-with-dysphagia-fever.html

Questions:

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

Ans:

Tracheoesophageal fistula is suggested by copious salivation associated with choking, coughing, vomiting, and cyanosiscoincident. Esophageal atresia and the subsequent inability to swallow typically cause polyhydramnios in utero.

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

Ans:

There are chances that patient may develop IRIS. 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.

             

7) Infectious disease and Hepatology:

Link to patient details:

https://kavyasamudrala.blogspot.com/2021/05/liver-abscess.html

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 ?

Ans:

Yes it can cause as he is drinking toddy since 30years. Amoebic liver abscess (ALA) is the most common manifestation of invasive amoebiasis caused by Entamoeba histolytica (EH). Several studies from India have reported a strong link between consumption of toddy and the occurrences of ALA. Toddy is a local alcoholic beverage consisting of fermented palm juice.

2. What is the etiopathogenesis  of liver abscess in a chronic alcoholic patient ? ( since 30 years - 1 bottle per day)

Ans:

according to some studies, alcoholism mainly consuming locally prepared alcohol plays a major role as a predisposing factor for the formation of liver abscesses that is both amoebic as well as pyogenic liver abscess because of the adverse effects of alcohol over the Liver. It is also proven that Alcoholism is never an etiological factor for the formation of liver abscess.

3. Is liver abscess more common in right lobe ?

Ans:

yes right lobe is involved due to its moreblood supply

4.What are the indications for ultrasound guided aspiration of liver abscess ?

Ans:

Indications for USG guided aspiration of liver abscess

B) Link to patient details:

https://63konakanchihyndavi.blogspot.com/2021/05/case-discussion-on-liver-abcess.html

QUESTIONS:

1) Cause of liver abcess in this patient ?

Ans:

Here ; the cause of liver abcess is :

* Amoebic liver abcess (ALA ) seen commonly in the tropics is predominantly confined to adult males, especially those who consume locally brewed alcohol, although intestinal amoebiasis occurs in all age groups and in both genders.

* It has been argued that socioeconomic factors and poor sanitary conditions are the primary culprits that casually link alcohol to ALA.

* However , there has emerged an abundance of data that implicates alcohol in a more causal role in facilitating the extraintestinal invasion of the infective protozoan and the subsequent development of ALA.

## Hence the consumption of locally made alcohol ( toddy ) is the most likely cause of Liver abcess in this patient.

2) How do you approach this patient ?

Ans:

The patient is well managed by treating team ; even me will follow the same approach.

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

Ans:

Considering the following factors:

    1) Age and gender of patient: 21 years ( young ) and male.

   2) Single abcess.

   3) Right lobe involvement.

## The abcess is most likely AMOEBIC LIVER ABSCESS … 

 

** But most of the patients with amoebic liver abcess have no bowel symptoms, examination of stool for ova and parasite and antigen testing is insensitive and insensitive and not recommended.

 

# And considering the risk factors associated with aspiration for pus culture:

1) Sometimes ; abcess is not accessible for aspiration if it is in posterior aspect or so.

2) Sometimes ; it has thin thinwall which may rupture if u aspirate.

3) Sometimes ; it is unliquefied.

## There how can u confirm whether it is pyogenic/ amoebic , so we treat them both empirically in clinical practice.

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

Ans:

he confirmatory test for amoebic abcess is

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

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

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

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

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

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

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

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

A) Link to patient details:

 

http://manikaraovinay.blogspot.com/2021/05/50male-came-in-altered-sensorium.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?

Ans:

1.     *3 years ago- diagnosed with hypertension

2.     *21 days ago- received vaccination at local PHC which was followed by fever associated with chills and rigors, high grade fever, no diurnal variation which was relieved on medication

3.     *18 days ago- complained of similar events and went to the the local hospital, it was not subsided upon taking medication(antipyretics)

4.     *11 days ago - c/o Generalized weakness and facial puffiness and periorbital oedema. Patient was in a drowsy state

5.     *4 days ago-  

a.     patient presented to casualty in altered state with facial puffiness and periorbital oedema and weakness of right upper limb and lower limb

b.     towards the evening patient periorbital oedema progressed

c.      serous discharge from the left eye that was blood tinged

d.     was diagnosed with diabetes mellitus

6.     *patient was referred to a government general hospital

7.     *patient died 2 days ago

pa  Patient was diagnosed with diabetic ketoacidosis and was unaware that he was diabetic until then. This resulted in poorly controlled blood sugar levels. The patient was diagnosed with acute oro rhino orbital mucormycosis . rhino cerebral mucormycosis is the most common form of this fungus that occurs in people with uncontrolled diabetes

The fungus enters the sinuses from the environment and then the brain.

Th The patient was also diagnosed with acute infarct in the left frontal and temporal lobe. Mucormycosis is associated with the occurrence of CVA 

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?

Ans: 

The proposed management of the patient was –

1.     inj. Liposomal amphotericin B according to creatinine clearance

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

Deoxycholate was the required drug which was unavailable

       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

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

Ans:

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

 

9) Infectious Disease (Covid 19)

As  these patients are currently taking up more than 50% of our time we decided to make a separate log link here:

http://medicinedepartment.blogspot.com/2021/05/covid-case-report-logs-from-may-2021.html?m=1

for this question that contains details of many of our covid 19 patients documented over this month and we would like you to:

1) Sort out these detailed patient case report logs into a single web page as a master chart 

2) In the master chart classify the patient case report logs into mild, moderate severe and 

3) indicate for each patient, the day of covid when their severity changed from moderate to severe or vice versa recognized primarily through increasing or decreasing oxygen requirements 

4) Indicate the sequence of specific terminal events for those who died with severe covid (for example, altered sensorium, hypotension etc). 

Ans:

As  these patients are currently taking up more than 50% of our time we decided to make a separate log link here:

 

http://medicinedepartment.blogspot.com/2021/05/covid-case-report-logs-from-may-2021.html?m=1

 

for this question that contains details of many of our covid 19 patients documented over this month and we would like you to:

 

1) Sort out these detailed patient case report logs into a single web page as a master chart 

 

2) In the master chart classify the patient case report logs into mild, moderate severe and 

 

3) indicate for each patient, the day of covid when their severity changed from moderate to severe or vice versa recognized primarily through increasing or decreasing oxygen requirements 

 

4) Indicate the sequence of specific terminal events for those who died with severe covid (for example, altered sensorium, hypotension etc). 

 

 https://docs.google.com/spreadsheets/d/e/2PACX-1vQuWFPoQm48IiBs1aDOGHPMosE9sylv2WdixecZa7xbmudlxrGMxk1O_1fgKpNxBbNPZLpIy37oQPcy/pubhtml

 

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

 

https://nikhilasampathkumar.blogspot.com/2021/05/covid-pneumonia-in-pre-existing-case-of.html

 

 

Questions: 

 

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

 

The pre-existing ILD significantly worsens the prognosis of this covid patient. 

Interstitial lung disease is characterized by dyspnea, decreased pulmonary diffusing capacity, decreased FVC and TLC. The SpO2 of these patients is usually decreased due to increased A-a gradient

A superimposed covid-19 infection in these cases can cause an acute exacerbation of symptoms such as dyspnea, decreasing levels of SpO2 further and faster than in Covid-19 patients without interstitial lung disease. 

Radiology (HRCT) usually shows the development of new pulmonary opacities and fibrosis.

Patient factors: 

Since this patient already had a reduced SpO2 of 90-92% (compared to the normal range of >96%) she is more susceptible to worsening of hypoxia and dyspnea unless immediate ventilator support is provided

The patient reportedly did not have dyspnea prior to the covid infection but developed a grade 2 SOB

ILD by itself makes the patient much more susceptible to acquiring Covid-19 infection.

Prognosis: Poor

 

Source: https://ejrnm.springeropen.com/articles/10.1186/s43055-021-00431-2

 

 

2) Why was she prescribed clexane (enoxaparin)?

The main pathogenesis of systemic inflammation caused by Covid-19 is by inducing a cytokine storm that causes epithelial cell necrosis, increased vascular permeability, dysfunctional humoral and CMI which all collectively lead to acute lung injury and ARDS

Of these cytokines, IL-6 is one that is the most important in determining the prognosis. IL-6 levels are highly elevated in patients with severe disease

Enoxaparin is said to relieve and prevent inflammation produced by IL-6 by inactivating it by binding it with its non-anticoagulant fraction, especially in pulmonary epithelial cells.

Moreover, patients with Covid-19 are more susceptible to the development of venous thromboembolism, which can be prevented by Enoxaparin (LMWH).

 

CASE 9-2: COVID-19 SEVERE

 

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?

 

The patient may have already had slight hyperglycemia, owing to high HbA1c levels (7.1%), which may have aggravated due to COVID-19. The possible biochemical pathways include: [6]

 

 

 

 

 

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

Yes, with DM or hypergycemia in patients leads to an increase in COVID-19 severity. Also, poor glycaemic control predicts an increased need for medications and hospitalizations, and increased mortality.

 

In monocytes: elevated glucose levels increase SARS-CoV-2 replication, and glycolysis sustains SARS-CoV-2 replication via the production of mitochondrial reactive oxygen species and activation of hypoxia-inducible factor 1α. Therefore, hyperglycaemia supports viral proliferation.

 

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

D- Dimer levels indicate the severity of COVID-19, pertaining to possible thrombotic complications- as D Dimer is formed post- fibrinolysis.

 

D- Dimer does change the management, as D-Dimer levels above 2000ng/dl were found to have a direct link with increasing severity of COVID-19 [7]. Moreover, D- dimer levels would be helpful in fast diagnosis and prevention of thrombotic complications.

 

 

 

 

CASE 9-3 (COVID-19 SEVERE)

 

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

 

QUESTIONS:

 

1. Why was this patient given noradrenaline?

Following kidney failure, the patient had sudden and persistent hypotension. To combat this, the patient was given noradrenaline, a potent vasoconstrictor.

 

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

LDH (Lactate Dehydrogenase) catalyzes the conversion of lactate to pyruvate and back. Hence, an increase in LDH denotes some form of tissue damage. In this patient, an increase in LDH levels would denote inflammation, and a high increase would denote Multi-Organ Failure.

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

Although BiPaP is a positive pressure system, unlike tracheal intubation, it does not send the air to the trachea and depends on the patient's ability to respire. In this patient, as SpO2 levels were dropping to 30% despite BiPAP, a more invasive method was required to push the air directly into the lungs- hence intubation was preferred.

 

CASE 9-4 (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? 

Yes, as ESR is an important indicator of immunological loss, and owing to an increased inflammation and immunological dysfunction in COVID, elevated ESR is most likely dur 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?

Hospitalisation was due to Grade 3 Shortness of Breath (SOB), and long duration of COVID-19 infection.

Challenges of home isolation-

Physical challenges- Many patients may find it hard to cut themselves from the outside world and confine themselves to a room for long periods of time

Emotional challenges- Sitting in a small room all day leads to stress, anxiety and even depression, with an increase in mental health issues being reported during the pandemic

Social challenges- Members of society who cannot care for themselves on their own (eg, patients with disability, geriatric patients etc) are at a major loss 

Economic challenges- Some patients, such as daily wage labourers, cannot afford to home isolate as they need to earn on a daily basis to keep their family going

Harms of hospitalisation-

Infection- Members visiting may get COVID from exposure to the hospital ward alone

Cost- PAtient may not be able to bear the brunt of high costs

Overtesting- Hospitals may ask the patients to stay overnight despite the conditions being mild, based on preliminary test results

Economic- Working patients may have to take a leave of absence, hence affecting both their work and decreasing their salary, on top of spending money on hospitalisation

         

 

 

CASE 9-5 (COVID-19 SEVERE)

https://anuragreddy72.blogspot.com/2021/05/case-discussion-on-hypokalemic-periodic.html

QUESTIONS:

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

The reason for coma is due to severe hypoxia, as his SpO2 levels were 20% when he was admitted. Along with this, hypokalemia leads to respiratory muscle paralysis, which may have aggravated his dyspnoea.

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?

The main competency gap was in the lack of testing for serum electrolytes, as the hypokalemia had caused weakness and fatigue in this patient. 

Hospital 2 make a diagnosis of hypokalemic periodic paralysis based on the fact that the patient had generalised weakness before becoming comatose, along with tingling and symptoms of paralysis. On testing serum electrolytes, his potassium levels were found to be 2.3 mEq/L (normal-3.5-5)

The coma was most probably related, as hypokalemia can cause respiratory muscle paralysis, leading to aggravation of hypoxia, hence causing unconsciousness in the patient.

3) How may covid 19 cause coma? 

Yes, as the brain is extremely sensitive to oxygen, oxygen deprivation due to COVID-19 can lead to a comatose state.

This patient had very low SpO2 levels (20%), which may have caused the coma.

 

 

 

CASE 9-6 (COVID-19 WITH ALTERED SENSORIUM)

https://vijaykumarkasturi.blogspot.com/2021/05/65-years-old-male-with-viral-pneumonia.html

QUESTIONS:

1. What was the cause of his altered sensorium?

Probable causes include

1. Altered sensorium due to hypoxia, leading to hypercapnic encephalopthy and altered sensorium

2. Increased urea levels leading to uraemic encephalopathy, which causes altered sensorium

 

2. what is the cause of death in this patient?

The cause of death in this patients was due to complications of COVID-19, most probably Acute Kidney Failure (AKI), as denoted by increased urea and creatinine, and hypoproteinemia. Hypoxia and inflammatory response due to COVID-19 may have triggered the process.

 

Source: https://www.frontiersin.org/articles/10.3389/fphar.2020.579886/full  

7) A 67 year old lady in the ICU with COVID induced Viral Pneumonia .

 

 

https://drsaranyaroshni.blogspot.com/2021/05/a-67-year-old-lady-in-icu-with-covid.html

Q1. What is the grade of pneumonia in her?

A. Based on the CT severity score it can be said that the patients pneumonia is moderate.

Q2. What is the ideal day to start steroids in a patient with mild elevated serum markers for COVID ?

A. It is best to start the treatment with dexamethasone before the onset of cytokine storm.

Q3. What all could be the factors that led to psychosis in her ?

A. The following can lead to ICU psychosis

Sensory deprivation

Sleep deprivation

Stress

Continuous light levels 

Continuous monitoring

Lack of orientation

pain

drug reactions

Infections

metabolic disorders

Dehydration

Q4. In what ways shall the two drugs prescribed to her for psychosis help ?

A. Pirecetam improves memory and causes cognitive enhancement and also improves mood.

Resperidone acts by decreasing the dopaminergic and seritonergic pathways in the brain

Q5. What all are the other means to manage such a case of psychosis?

A. The management of ICU psychosis primarily depends on the cause. If it is sleep deprivation then hte patient should be provided a peaceful place to take rest.

If it is due to underlying conditions like heart failure and dehydration then these should first be corrected. 

Haloperidol is a medication commonly used to manage ICU psychosis. Other common anti-psychotics can also be used.

 

 

 

 

Q6. What all should the patient and their attendants be careful about ( w.r.t. COVID )after the patient is discharged ?

A. The patient is supposed to self isolate after they are discharged for another 7 days after discharge. If possible oxygen levels are to be monitored as well for the next 7 days. The patients and the patient's attenders should be on the look out for danger symptoms such as 

trouble breathing, chest pain, bluish discolouration of lips, confusion or inability to wake up.

Q7. What are the chances that this patient may go into long covid given that her "D Dimer" didn't come down during discharge? 

A. Long COVID is the persistence of symptoms such as cough, breathlessnes, headaches and chest pain weeks to months after discharge. People suffering from long COVID usually have elevated biomarkers such as elevated d dimer and CRP. As this patient has elevated d dimer levels at discharge there is a good chance that she could suffer from long COVID.

 

 

8) 35YR/M WITH VIRAL PNEUMONIA SECONDARY TO COVID 19 INFECTION

https://bhavaniv.blogspot.com/2021/05/35yrm-with-viral-pneumonia-secondary-to.html?m=1

 

Q1. Can psoriasis be a risk factor for severe form of COVID?

A. There is no evidence that patients with moderate-to-severe psoriasis receiving systemic treatments, including biologics, have higher risk of SARS-CoV-2 infection and/or increased hospitalization and death related to COVID-19 compared to the general population.

Q2. Can the increased use of immunomodulatory therapies cause further complications in the survivors?

A. Immunomodulators help COVID 19 patients by suppressing the cytokine storm  but they also have thepotentialt to increase the risk of infection  (like mucormycosis), traditional clinical signs may be masked with resulting delays in identification and treatment.

Q3. Is mechanical ventilation a risk factor for worsened fibroproliferative response in COVID survivors?

A. Increasing evidence from experimental and clinical studies suggests that mechanical ventilation, which is necessary for life support in patients with acute respiratory distress syndrome as seen in COVID 19  can cause lung fibrosis, which may significantly contribute to morbidity and mortality. It is believed that ventilator induced lung injury is the cause for the fibroproliferative changes and the resultant lung fibrosis.

9) 45 year old female with viral pneumonia secondary to Covid-19

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

Q1. What is the type of DM the patient has developed ?(is it the incidental finding of type 2 DM or virus induced type 1DM)? 

A.  Incedental type 2 DM can be differentiated from de novo covid induced type 1 DM with the help of the HbAc1 levels.

As HbAc1 levels are indicators of long term blood ssugar levels they are likely to be raised in pre existing DM that was incidentally discovered. But in case ofthe diabetes being de novo in nature then the HbAc1 levels are unlikely to be raised. As the patients HbAc1 levels are not raised we can not at this point determine if the patient has incedental discovered type 2 DM or Covid induced de novo DM.

Q2. Could it be steroid induced Diabetes in this patient?

A. As the patient was given dexamethasone as a part of her treatment regimen it is possible that her elevated glucose levels are a result of steroid induced hyperglycemia.

 

10) A little difference that altered the entire covid recovery game: a report of two patients with focus on imaging findings.

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

Q1. What are the known factors driving early recovery in covid?

A. The following factors can lay a role:

Younger age ggroup

shorter duration of fever 

No diabetes

PaO2/FiO2 levels

No comorbidities

 

11) Viral pneumonia secondary to COVID of a  denovo Diabetes Mellitus

https://rishithareddy30.blogspot.com/2021/05/covid-case-report.html

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? 

A. People suffering from diabetes are like to experience more severe symptoms of the disease than the ones who are not diabetic. Even within the patients that are diabetic the people whose disease is under better control tendtendvbe better diagnosis.

Possible causes for de nov diabetes in COVID19 include:

·         The SARS CoV 2 virus enters the cells through the ACE 2 receptors which are present in large  numbers in the pancreas and that this damages the pancreatic cells.

·         Another theory is that the inflammation caused by the cytokine storm damages the beta cells.

 

Q2. Why couldn't the treating team start her on oral hypoglycemics earlier?

A.      As the insulin is faster acting as compared to oral hypoglycemics and as her blood glucose level was very high it is important to bring it down as fast as possible.

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 bio clinical markers in this patient that may have predicted the prolonged course of her illness? 

 

Serum LDH: 571U/L      (Normal range=140-280U/L

ALP : 342 U/L                (Normal range=44-147U/L)

SpO2: 82% at RA           (Normal range= >96%)

HR: 124bpm                   (Normal range=60-100bpm)

Classically, the bio clinical markers that are predictive of a Covid-19 patient's outcome are

C reactive protein [>57.9mg/dL]

D-Dimer [>1mcg/ml associated with poorer prognosis]

Serum LDH [>248U/L]

IL-6 [2.9 times higher in severe disease compared to mild disease]

SGPT [Isolated rise in SGPT >3 times the normal value]

ESR [high sustained level after recovery from infection]

Albumin

Platelet count 

Neutrophil count

NLR: [>5.5]

Urea

Creatinine

High sensitivity Troponin

The patient in question has elevated levels of serum LDH and ALP. Her CRP and D-Dimer levels are not high enough to be considered as a bad prognostic factor.

 

Sources: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7219356/

               https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7194951/

               https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7896696/

13) Severe covid with first diabetes 

 

Link to Case report log :

 

https://vignatha45.blogspot.com/2021/05/58-years-female-patient-with-viral.html

 

 

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

Hyperglycemia can lead to anomalous glycosylation of tissue receptors throughout the body. One of these receptors happens to be ACE2, the same receptor SARS-CoV2 uses to gain entry into the host cell. In fact, glycosylation of ACE2 is necessary for the virus to establish an infection.

Uncontrolled hyperglycemia freely facilitates this glycosylation, making these patients more susceptible to Covid-19 infections and increasing the severity of the infection by helping increase the viral load (by increasing the concentration of glycosylated ACE2) 

Control of blood sugar can also decrease the chances of a cytokine storm during the second phase of the infection.

Uncontrolled hyperglycemia hence, suggests a poor prognosis in Covid-19 patients.

Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7188620/#:~:text=Therefore%2C%20high%20and%20aberrantly%20glycosylated,and%20a%20higher%20disease%20severity.

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

 

Lactate dehydrogenase has 5 isoenzymes that are present in various tissues such as the heart, RBCs, lungs, liver, kidney, brain, and skeletal muscle.

Since covid-19 primarily causes lung damage, LDH3 is released into the blood giving an elevated titer.

Multi-organ damage that involves the heart (myocarditis) or kidneys (renal failure) can lead to an elevation in respected isoenzymes found in these tissues.

Hence, a significant rise in LDH indicates a poor prognosis and points towards multi-organ damage.

Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7251362/

 

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

 

This patient was diagnosed with uncontrolled hyperglycemia with severe covid pneumonia.

LFT shows elevated AST, ALT, and ALP with a gross increase in bilirubin titer. 

The D-Dimer is elevated (560ng/ml) and the LDH is 835U/L both of which are indicators of a poor prognosis. 

The most likely cause of death in this patient seems to be ARDS. 

The immediate cause of death: Most probably cardio-pulmonary arrest

Antecedent cause: Severe covid-19 pneumonia

 

 

14) Long covid with sleep deprivation and  ICU psychosis 

 

 

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?

 

Hyperactive delirium: Manifests as agitation, restlessness, refusal to cooperate with caregivers, unprovoked mood changes, hallucinations

 

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

Hypertension

History of cerebrovascular accident (makes him more prone to a new one)

Steroid use

Sedative use (Gabapentin)

COPD

 

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

 

 A) Sleep deprivation causing ICU psychosis

 

 B) ICU psychosis causing sleep deprivation 

 

B) ICU psychosis causing sleep deprivation is more likely in this patient

 

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

 

Elevated bio clinical markers like D-Dimer, LDH, Neutrophils, WBCs(absolute), IL-6, and CRP all contribute to persistent hypoxia and worsen the prognosis. In addition to this, ICU psychosis adds to the prolonged hospital stay.

 

15) Moderate Covid with comorbidity (Truncal obesity and recent hyperglycemia) 

 

 

 

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 a transient rise in blood glucose?

 

Cortisol stimulates gluconeogenesis in the liver and inhibits glycogen synthesis, increasing blood glucose. Continuous treatment with corticosteroids can lead to elevated blood glucose titers even in non-diabetics.

 

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

 

It is still unclear if the alterations brought about by covid-19 in the glucose metabolism are permanent and persist or remit after the resolution of infection. There are ongoing studies that aim to answer these questions.

Steroid diabetes is a term coined to describe diabetes mellitus arising as a result of glucocorticoid use for more than 50 years

 

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

 Hyperglycemia in general is indicative of a poorer prognosis in a patient compared to covid patients with normal blood glucose levels.

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

 

Oral hypoglycemics (such as sulfonylureas) are efficient at controlling blood glucose levels in non-diabetics who develop steroid-induced hyperglycemia. Most cases revert to normoglycemia after discontinuation of steroids.

 

5. What is thrombophlebitis fever? 

 

Fever in response to thrombophlebitis that is caused due to release of inflammatory mediators 

 

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

 

No, infusion thrombophlebitis is not grounds for discontinuation of infusions that are essential for the treatment of the case. Thrombophlebitis can be treated by local compressive dressings, NSAIDs (topical and/or systemic)

 

16) Mild to moderate covid with hyperglycemia 

 

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?

 

The possible factors that could have led to precipitation of diabetes in a covid-19 patient are:

Genetic susceptibility to diabetes

Pre diabetic state

Viral insult to the beta cells of the pancreas

Stress hyperglycemia due to inflammation-induced insulin resistance

High dose steroid usage

 

 

 

 

17) Covid 19 with hypertension comorbidity 

 

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

 

 

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

Yes, hypertensive patients are at a higher risk of COVID 19 severity. It is already known that hypertension is assocatied with a weaker immune system and is seen in older patients which show bad prognosis when dealing with this infection. As there is a high risk of developing cardiovascular events as well as end organ failure.

 

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

Pneumonia caused due to COVID-19 infection lead to increase permeability of microvascular circulation which lead to pleural effusion(exudative type)

 

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?

The reason for hypoalbuminemia in COVID_9 patient is due to increased catabolism of albumin to make amino acids as well as simulataneous decrease in albumin synthesis( albumin is a negative acute phase reactant that means its level decrease during inflammation)

 

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

     Exanthem is an eruptive skin rash seen in viral infections. Yes, this could be due to COVID-19 infection. The exanthem in COVID-19 resembles that of varicella.

 

2.       What is the reason for Cardiomegaly?

High blood pressure might be the underlying cause for cardiomegaly in this patient.

Uncontrolled high blood pressure leads to increase in work load of the heart. To compensate this demand, the ventricles undergo remodelling leading to cardiomegaly.

 

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

·         Chicken pox

·         Shingles

·         Pytriasis

 

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

D-dimer is increased in a COVID-19 patient. It may be related to the viral life cycle. The apoptotic processes target the endothelial cells of the vasculature resulting in triggered coagulopathy and ultimately result  in increased d-dimer levels.

 

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???

COVID-19 infection causes systemic inflammation and cytokine storm. In order to prevent these severe conditions steroids are used.

A well-known adverse effect of steroid usage is the disruption in carbohydrate metabolism. It leads to hyperglycemia. When steroids are given to a diabetic COVID-19 patient utmost care must be taken. The patient should be shifted from oral anti diabetic drugs to s.c. insulin and blood sugars should be closely monitored. If possible, Tocilizumab should be used instead of steroids.

Steroid usage in diabetic patient has shown a increase in death rate as it further decreases the immunity of the patient and make them prone to other opportunistic infections like mucormycosis leadth to inceased death rate.

 

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

In COVID-19 infection due to systemic inflammation and cytokine storm even when they are adequately managed, ae leading to damage of inner walls of small blood vessels of the brain. These blood vessels have very little or no collateral blood supply.

Even though the patient is on blood thinners they cannot prevent this damage. When the blood viscocity becomes higher either due to dehydration or high LDL/cholesterol levels, these small blood vessels are blocked leading to stroke.

 

3)Does chronic alcoholism  have effect on the out come of Covid infection?If yes,how?

Yes, chronic alcoholism does worsen the prognosis of COVID-19 patient.

One of the adverse effect of chronic alcoholism is its ill effect on innate as well as adaptive immunity.

Reduced resistance to COVID-19 promotes progression of disease and leading to wrose prognosis

 

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?

it is observed that there is a early as well as aggressive progression of COVID 19 in diabetics. This is attributed to interactions of several risk factors as well as hyperglycemia which is seen in diabetic patients. It modulates immune response as well as inflammatory responses thus predisposing individuals to lethal course of the disease.

 

 

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

methylprednisolone from 40 mg/day to 160 mg/day for 6 days according to the weight and status of the patients. During this course of treatment, blood sugar should be closely monitored and patient should be shifted from oral anti diabetic drugs to insulin.

 

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

It is established that COVID-19 is associated with coagulopathy. In a patient who has a history of CVA are mostly old and have other co-morbidities which leads to severe course of the disease as well as poor prognosis.

 

23) Covid 19 with multiple comorbidities:

 

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

 

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

·         Old age

·         Diabetes mellitus type 2

·         Chronic kidney disease

·         Bronchial asthama

 

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

It may be related to the viral life cycle. The apoptotic processes target the endothelial cells of the vasculature resulting in triggered coagulopathy and ultimately result in increased d-dimer levels

 

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

·         Head elevation

·         O2 supplementation

 

 

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)

During the early stage diabetes, there is a increase in blood flow to the kidneys, which strains the glomeruli and lessenstheir ability to filter blood. High levels of glucose in the blood leads to accumulation of extra material in glomeruli. It increases the stress of glomeruli inturn leading to gradual and progressive scarring. Eventually leads to the development of CKD.