Bimonthly assessment by Maddipati Sridevi

 

BIMONTHLY EXAM FOR THE MONTH OF FEBRUARY

Case:1

50 year man, he presented with the complaints of

Frequently walking into objects along with frequent falls since 1.5 years

Drooping of eyelids since 1.5 years

Involuntary movements of hands since 1.5 years 

Talking to self since 1.5 years 

Following are the links 

https://archanareddy07.blogspot.com/2021/02/50m-with-parkinsonism.html?m=1

You tube link of the case:

https://youtu.be/kMrD662wRIQ

He was a 50 year old who is a diabetic since 9 months came with complaints of 
Frequently walking into objects along with frequent falls since 1.5 years ,  drooping of eye lids since 1.5 years , involuntary movement s of hands since 1.5 years
Talking to self since 1 . 5 year, bed wetting since 1 year
He also has reduced arm swing

1 a. What is the problem representation of this patient and what is the anatomical localization for his current problem based on the clinical findings? 

Ans:ANATOMICAL LOCALIZATION TO HIS PROBLEMS

The anatomical location is in Brain (in the Basal ganglia and substantia nigra ) addressing his problem of frequent falls 

Drooping of the eyelid also known as Ptosis. Ptosis may result from damage to the nerve that controls the muscles of the eyelid, problems with the muscle strength (as in myasthenia gravis)
Nocturnal enuresis suggest that the frontal lobes in general, and the superior frontal gyri in particular, as they are important in volitional bladder control.

Involuntary movement s of hands/ tremors could be due to Muscle fatigue

1 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 his problems and current outcomes.

Etiology:

Progressive supranuclear palsy (PSP) also known as Steele-Richardson-Olszewski is a neurodegenerative disease  whose characteristics include supranuclear, initially vertical, gaze dysfunction accompanied by extrapyramidal symptoms and cognitive dysfunction. The disease usually develops after the sixth decade of life, and the diagnosis is purely clinical.

The other differential  include  Myasthenia gravis as the patient complained of ptosis which progressed by the night. We performed an Ice Pack test to rule out Myasthenia Gravis. After an Ice pack test, in Myasthenia Gravis, the eyelid droop improves by atleast 2-3 mm, which wasn't seen in this patient & also the drooping of his eyelids were intermittent

Series of events:

Seizures 10 years back

Type 2DM 2 years back

Sudden blurring of vision while riding bike met with RTA -- fracture in left leg ,operated 2 years back

Frequently walking into objects along with frequent falls,drooping of eyelids,Involuntary movements of hands,Talking to self 1.5 years backS

Stopped alcohol & tobacco consumption 1 year back

Non productive cough 8 months backo

Non healing ulcer at surgical site 7 months back

For 1 week - diagnosed as PSP & discharged with SYNDOPA 110 MG & QUETIAPINE

 5 days later patient presented to casualty in a state of unresponsiveness with GCS: 3/15 with H/o 2-3 episodes vomiting.

Another 2 episodes of generalized tonic seizures in casualty - treated with levipil

Suddenly his saturations & heart rate dropped with no peripheral pulsations and patient was intubated - CPR done and was resuscitated.

Currently on mechanical ventilator on cpap

C)What is the efficacy of each of the drugs listed in his current treatment plan 

Quetiapine:

It is used to treat psychosis in PSP

SYNDOPA: helps parkinson as well as psp according to ncbi 

Case:2

Patient was apparently asymptomatic 2 years back then he developed weakness in the right upper and lower limb, loss of speech.

Links below

https://ashfaqtaj098.blogspot.com/2021/02/60-year-old-male-patient-with-hrref.html?m=1

htpps://youtu.be/7rnTdy9ktQw

a). What is the problem representation of this patient and what is the anatomical localization for his current problem based on the clinical findings?

Problem presentation:

60 year old male non diabetic & non hypertensive who had a history of CVA 2 years back

 Now presented with c/o SOB,pedal edema,decreased urine output & generalized weakness since 2 months.

Anatomical localization: 

Heart - HFrEF secondary to CAD with EF 36 PERCENT

His examination findings were Visible apical impulse, Pericardial bulge, visible pulsations, dilated veinsshift of apex beat to 6th ICS, Thrill at the apex, Loud S1 present, loud P2 present, S3 Accentuating on inspiration- RVS3, Expiration - LVS3

His Ecg shows poor R wave progression

Chest Xray PA shows Cardiomegaly 

His 2Echo is suggestive of Heart failure DCMP with Hypokinesia at RCA, LCX

Anatomical diagnosis:

The location to his problems is at the Heart, secondary to atherosclerosis of the vessels

Risk factors:

Alcohol

Age of 60 years

Male gender

B)Etiology to his current problems :

CAD leading to DCMP

Diagnosis:DcmP with an EF of 34% secondary to CAD

CVA 6 months back (? Left ischaemic stroke)

Sequence of events:

CVA ,2 years back

and

SOB, pedal edema, decreased urine output & generalized weakness since 2months

and

Treated with diuretics(aldosterone antagonist) and beta blockers ,ARB

With salt and Fluid restriction.

Outcome: Symptomatically improved and discharged

c) What is the efficacy of each of the drugs listed in his current treatment plan 

Salt and fluid restriction

https://pubmed.ncbi.nlm.nih.gov/23787719/#:~:text=Conclusion%3A%20Individualized%20salt%20and%20fluid,Quality%20of%20life%3B%20Salt%20restriction.

Ninety-seven stable patients in NYHA class II-IV, on optimal medication, with previous signs of fluid retention, treated with either >40 mg (NYHA III-IV) or >80 mg (NYHA II-IV) of furosemide daily were randomized to either individualized salt and fluid restriction or information given by the nurse-led heart failure clinics, e.g. be aware not to drink too much and use salt with caution, and followed for 12 weeks. Fluid was restricted to 1.5 L and salt to 5 g daily, and individualized dietary advice and support was given.

Results After 12 weeks, significantly more patients in the intervention than in the control group improved on the composite endpoint (51% vs. 16%; P < 0.001), mostly owing to improved NYHA class and leg oedema. No negative effects were seen on thirst, appetite, or QoL

Benfomet as thiamine replacement in alcoholic patients

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4550087/

Case:3

52 year old male , shopkeeper by profession complains of SOB, cough ,decrease sleep and appetite since 10 days and developed severe hyponatremia soon after admission. 

Morehere:

https://soumya9814.blogspot.com/2021/01/this-is-online-e-log-book-to-discuss.html?m=1

Case presentation video:

https://youtu.be/40OoVEQBgS4

a) What is the problem representation of this patient and what is the anatomical localization for his current problem based on the clinical findings?

Problem representation: 

A 52 year old who is diagnosed hypertensive and diabetic came with complaints of dyspnea since 10 days , cough since 2 days, dcreased sleep&appetite , complaints of anemic symptoms

Anatomical localization: 

Anemia - Nutritional(iron and B12 deficiency)

Hyponatremia -SIADH or dilutional

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 his problems and current outcomes. 

Etiology:

Dimorphic anemia may be secondary to ? Nutritional 

Hyponatremia secondary to free fluid (dilutional) or poor sugar control (hyperglycemia)

Sequence of events:

Type 2 DM & HTN since 1 year

And

SOB,Cough

Decreased sleep and appetite (10 days)Admitted

Diagnosed with Dyselectrolytemia (hyponatremia)

Treated conservatively & discharged

c) What is the efficacy of each of the drugs listed in his current treatment plan especially for his hyponatremia? What is the efficacy of Vaptans over placebo? Can one give both 3% sodium as well as vaptan to the same patient?  

Can be given if it is SIADH tolvaptan can be given.

3percent NS may not be necessary because sodium levels here are 131 near to normal lower limit,no need of correction acutely.

4) Please mention your individual learning experience from this month

Being posted in general medicine, being an intern here is different and new experience compared to other postings and I am loving it

Learnt how to make e logs 

Few of the blogs I have made:

https://sridevimaddipati.blogspot.com/2021/01/55-year-old-male-with-chronic-heart.html?m=1
https://sridevimaddipati.blogspot.com/2021/02/75-year-old-with-fever-under-evaluation.html?m=1
https://lifeonmoon88.blogspot.com/2021/02/pancreatitis-with-pseudocyst.html?m=1

Few of the cases : 

A case of Dimorphic anemia ( nutritional) , k/c/0 hypertension and diabetic, heart failure ( low output cardiac state), who is diagnosed SIADH, also with recurrent complaints of fluctuating and uncontrollable sugars despite administration of Antidiabetogenic drugs

Acase of  fever under evaluation. 

A case of chronic heart failure

A case of Cushing syndrome

A case of gastroenteritis

A case of cervical myelopathy, secondary to OPLL

? Fibrosis? With upper lobe collapse ad multiple cavitatory lesions in both lungs

A case of aphasia( frontal lobe? Involuntary) 

A case of heart failure with reduced ejection fraction

 

A case of new onset seizures secondary to hypertension. 

Thank. You