BI- MONTHLY ASSESSMENT FOR THE MONTH - FEBRUARY

BIMONTHLY ASSESSMENT FOR THE MONTH OF FEBRUARY :

This is my submission for the Bimonthly internal assessment for the month of February."

The questions to the cases being discussed can be viewed from the link below 


https://medicinedepartment.blogspot.com/2021/02/medicine-paper-for-february-2021.html?m=1


1Q.  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 




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


This  case came to OPD on 10/2/21.

Coming to the case,

He was 50yr old who was diagnosed as diabetic  9 months back came with 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 

Bed wetting since 1 year

He had reduced arm swing

H/O suicidal attempt present.

ANATOMICAL LOCALIZATION TO HIS PROBLEMS:

* Drooping eyelids ...oculomotor nerve is the nerve supply . It's arises from midbrain 

*Involuntary movements and frequent falls

Suggests of Basal Ganglia involvement 

*Self talking and bed wetting- frontal lobe (Pre frontal area Broadmann 8,9)

*Suicidal attempt - ?involvement of limbic system (temporal lobe area)


AS MULTIPLE AREAS OF BRAIN WERE INVOLVED I WOULD PROBABLY GO IN FAVOUR OF  a NEURODEGENERATIVE DISORDER


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.

I came over two differential diagnosis for the current case :

1.PROGRESSIVE SUPRANUCLEAR PALSY (PARKINSON PLUS SYNDROME) 

Superior gaze palsy,frequent walking into objects and frequent falls,drooping of eyelids goes in favour

The important Differential is

2.MYASTHENIA GRAVIS .

It is ruled out after performing an ICE PACK Test.

There is no significant improvement of ptosis 

And also there is no progressive weakness as the day progresses which is a characteristic of MG.



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 back

--)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 

The patient was put on Syndopa and 
Quetiapine

The below links shows efficacy of drugs based on randomised control trails

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2699657

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2699657/



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


Case presentation  links: 


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

Problem representation:

A 60 year old man with a history of CVA 6 months back presented with 

Dyspnea since 2 months 

Bilateral pedal edema since 2 months

Reduced urine output since 2 months 

Generalised weakness since 2 months


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

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 60 year old man with a history of CVA 6 months back presented with 

Dyspnea since 2 months 

Bilateral pedal edema since 2 months

Reduced urine output since 2 months 

Generalised weakness since 2 months


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

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://www.sciencedirect.com/science/article/pii/S2213177915006551


Benfomet as thiamine replacement in alcoholic patients


Randomized Aldactone Evaluation


 TELMISARTAN AND METOPROLOL:



3Q. 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. 


Case presentation video:


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 man, who is a known to be a Diabetic and hypertensive presented with:

Dyspnea since 10 days

Productive cough since 2 days

Disturbed sleep since 10 days


Anatomical localization:

The anatomical location of the problem is in the lungs

Lower respiratory tract infection


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. 

No respiratory examination has been mentioned in the elog.

However his problems list are:

- Hyponatremia

-Lower respiratory tract infection

-Uncontrolled blood sugars

-Dimorphic Anemia


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.


It was a heavily rewarding experience and i consider it my privilege to work with such experienced and enthusiastic doctors. I found it highly motivating and i have learnt so much about patient interventions and about interacting with the patients. I especially found the 2-4, sessions to be filled with such learning oppurtunities and coming to GM has taught me that a DOCTOR IS ALWAYS A STUDENT. 
The zeal with which every person in the department works is so inspiring and the guidance i got from PGs and the work conditions were very good. 

The following are some of them

1. Complete follow-up of cases that came to OPD
2. Performed High quality CPR to an ICU patient 
3.Demostration of EAD
4.Performed a Lumbar Puncture
5.Assissted in a central vein placement
6. Pleural tap and ascitic tap done on CKD patient
7.Attended daily ward rounds and learnt about the new drugs used and their efficacies

The following are the cases that I have seen:
On 3/2/21
1. A 50 year man with Progressive supranuclear palsy

2. A 41 year man with Pancreatic pseudocyst

3. 73 year man with CAD showing a bifascicular  block on the ECG posted for left inguinal hernia surgery

4. 50 year old man with HFrEF

5. 45 year man with Fever and Rash

On 17/2/21

1. 70 year man with ? SAH, ?Meningitis ? Uremic Encephalopathy with AKI with Bilateral Hydronephrosis

2.29 year man with Heart failure with reduced EF, LRTI and ? Myopathy

3.52 year man with HFREF, known Diabetic and Hypertensive

4.65 year woman with HFREF secondary to IHD, Anemia under evaluation, a known diabetic and hypertensive

5.42 year man with Nephritic syndrome and Heart failure

6.A 40 year woman with Fever under evaluation

7. A 30yr man with Enteric fever

8.60 year man with HFREF, CKD Stage 5, known diabetic and hypertensive

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