Bimonthly assessment for the month of feb 2021

Submission of bimonthly assessment for the month of feb 2021

Q.1) Please go through the patient data in the links below and answer the following questions:

50 year man, he presented with the c/o

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

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

Case presentation links: https://youtu.be/kMrD662wRIQ

Problem presentation-

⏩Involuntary movements of both upper limbs

⏩Drooping of eyelids

⏩Talking to self

⏩Frequent falls (while walking on steps)

All the above from 1.5 years.

Localisation of lesion-

➡Drooping of eyelids is called as ptosis

and our patient has Bilateral ptosis

B/l ptosis - is because of weakness in levator palpebrae superioris muscle and muller muscle which is because of ------

1)⏩➡muscle involvement

2) ⏩➡nerve involvement (3rd cranial nerve)

3) ⏩➡nucleus involvement (ie central caudal nucleus of oculomotor complex)

https://www.sciencedirect.com/topics/medicine-and-dentistry/levator-palpebrae-superioris-muscle

➡Involuntary movements of upper limbs-we can categorize under movement disorders

https://www.researchgate.net/figure/Differential-Diagnosis-of-Involuntary-Movements_tbl1_233603232

➡Talking to self - frontal lobe lesion

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

B/l ptosis-

https://www.medicaleducationleeds.com/paces/ptosis/#:~:text=Differential%20Diagnosis%20of%20ptosis%3A,Horner's%20syndrome

Classification of ptosis-

⏩Neuropathic--3rd nerve palsy, horner syndrome

⏩Neuromuscular junction -Myasthenia gravis, Botulism

⏩mechanical-lid tumors

⏩myogenic-myotonic dystrophy

Arriving at a diagnosis

The size of pupils o/e normal:rules out horner's or 3rd nerve palsy(as a single nucleus supllies both levator palpebral superioris ,its lesion causing b/l ptosis

myasthenia gravis -no history of fatiguable ptosis (can be diagnosed by ice pack test)

Self talk -frontal lobe lesion

Frequent falls while climbing steps -indicate vertical gaze of patient affected.

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

Pts with psp are said to have minimal or no response to levodopa

Currently there is no specific treatment or cure for PSP. Treatment is focused primarily on symptomatic improvement and, ideally, should involve a multidisciplinary team approach including physical and occupational therapy, speech pathology, neuropsychology, psychiatry, social work, and palliative care. Physical therapy is critical for gait and postural instability, fall prevention, and to develop an exercise program to maintain mobility. Occupational therapy can help patients (and caregivers) with activities of daily living. Speech therapy is important early on to treat dysarthria. More advanced patients may need cognitive therapy for speech apraxia or to discuss alternative communication modes if markedly dysarthric or anarthric.

Source https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5567217/

2-Question

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

Case presentation links:

https://youtu.be/7rnTdy9ktQw

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:

⏩Sob on exertion grade 2 progressed to grade 4 ( on rest) with orthopnea and paroxysmal nocturnal dyspnea.

⏩Bilateral pedal edema up to knee since 2 months

⏩Decreased urine output and generalized weakness since 2months

⏩loss of speech persisted from 2 years after patient had weakness in right upper and lower limb (hemiparesis)

anatomical localization :

⏩ History suggests sob 2 to 4 (even on rest), orthopnea and paroxysmal nocturnal dyspnea.

Classical symptoms of left heart failure (first most common cause)

⏩

Examination findings -

➡Apex beat at 6th ICS - probably because of ventricular hypertrophy apex beat being displaced.

➡Pedal edema upto knee Grade 2 ---maybe because the patient might have developed features of right heart failure too (2nd most common cause)

➡Loud p2

➡ Bilateral fine Crepitations present in axillary,infra axillary and infrascapular areas.

etiology:

CAD

Ecg showing

1)normal axis

2)pathological Q waves from v1 to v6

3)poor R wave progression

suggest a CAD probably involving LAD and LCX

sequence of events(probable hypothesis)

Based on history -male and being addicted to alcohol (quantity and duration not being mentioned)

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Leads to depletion of NADPH and thus affects glutathione perioxidase

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Resulting in formation of ROS reactive oxygen species ➡damages tissues

2) Alcohol overintake

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Deranged lipid profile

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Atherosclerosis of vessels

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Affecting coronary vessels

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Myocardial infarction

Alcohol metabolism---

Further events

Alcoholic cardiomyopathy

⏬

Myocardial infarction

⏬

Ventricular remodelling

⏬

Ventricular dilation

Source --https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2365733/

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

1)salt and fluid restriction

Source ---https://pubmed.ncbi.nlm.nih.gov/23787719/

Methods and results: 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. The 24 h dietary recall procedure, urine collection on three consecutive days, and para-aminobenzoic acid 80 mg t.i.d. was used to assess adherence to diet and completeness of urine collection. The primary endpoint was a composite variable consisting of NYHA class, hospitalization, weight, peripheral oedema, quality of life (QoL), thirst, and diuretics. 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.

2)Spironolactone

Source -https://www.aafp.org/afp/2001/1015/p1393.html

Based on earlier work suggesting a benefit of therapy,2 the Randomized Aldactone Evaluation Study (RALES) was undertaken to evaluate the role of spironolactone when used in addition to standard therapy for CHF. Standard therapy in this study did not include beta blockers.3 The investigators prospectively enrolled 1,663 patients with severe (New York Heart Association [NYHA] class IV) CHF (Table 1).4 Most of the enrolled patients were white men averaging 65 years of age. These patients had a left ventricular ejection fraction of 35 percent or less and marked physical limitations related to CHF. Patients were excluded if they had unstable angina or moderate renal failure, and if they were hyperkalemic.

3)benfomet as thiamine replacement in alcoholic pts

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

4) furosemide

Source https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2014966/

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.

More here 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 presentation --

⏩Sob grade 2 progressed to grade 3

⏩cough with sputum,whitish in colour non foul smelling since 2 days

⏩decreased sleep and appetite since 10 days

Anatomical localisation--

Sob grade 2 to 3 without complains of palpitations , chest pain ,orthopnea and pnd

can be attributed to lung problem.

Ans--

Etiology-

Based on history --

Sob 2 to 3,generalized weakness, decreased appetite (anemia causing heart failure)

O/E - on examination of lower palpbreal conjuctiva -pallor+

Sequence of events

50 year old with gradual reduction in hemoglobin

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Developed symptoms of sob, ⬇sleep and appetite, generalized weakness

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Eventually patient developed heart failure.

Also he took statins for an year and is a k/c/o type 2 dm

Diagnosis- patient admitted in view of correcting anemia and blood sugars.

Treating team started patient on human insulin..... After starting insulin, patient developed weakness and for evaluating hypokalemia caused due to insulin injection--- the team sent a serum electrolyte sample ---- Thus hyponatremia 121 came as a incidental diagnosis. (Developed drowsiness)

⏩Our treatment team would initially sent a urinary sodium and serum electrolyte sample

to differentiate between types of hyponatremia.

⏩1) First -restricting fluids with minimal intake of hypertonic saline 3%

Calculation of the sodium deficit:

0.6 x weight(kg) x (desired Na+ - Actual Na+). Use 0.5 for females. Desired Na+= 120-125 meq/l.

Example: 70kg male. Na+= 110 meq/l Desired target= 125 meq/l.

[0.6 x 70kg x (125-110)= 630 meq of Na+ needed].

Amount needed to increase serum sodium level by 1 meq/l/hr= 0.6 x 70kg x 1.0= 42 meq/hr (safe rate for this patient).

3%--hypertonic saline contains 513 meq/liter.

Therefore: [desired rate per hr] / 513 x 1000 = infusion rate (ml/hr).

And the total infusion time= [total meq needed] / [meq/hr]

Desired rate= 42/513 meq x 1000= 82 ml/hr

Infusion time= [630 meq] / [42 meq/hr] = 15 hrs.

Therefore: Infuse 3% saline at 82 ml/hr for 15 hours.

Source---

https://globalrph.com/dilution/sodium-chloride/

⏩Maximum correction for Na which can corrected in a day is 8-10 meq

⏩First 4 hrs -4meq has to be corrected

⏩Next 20 hrs -remaining calcuated Na should be given

⏩we have to control sugars since for every 100mg increase in sugars, 1.6 Na will decrease (remembered as sweet 16🤩)..

However in a type 2 diabetic we consider 124 too as normal Na range

Source of the above points =2-4 Class

2) proper control of sugars with insulin and metformin

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 patients?

Answer--

1) Efficacy of vaptans over placebo

https://acsjournals.onlinelibrary.wiley.com/doi/full/10.1002/cncr.28468

2) Can one give both 3% sodium as well as vaptan to the same patient?

No,

We shouldn't give both at a time.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5752787/

Q.4 .Please mention your individual learning experiences from this month.

1) Understood relations, medical ethics, medical etiquette.

2) Learnt few interesting things --