Bimonthly Internal Assessment - November
Case 1 :
55 year old male patient came with the complaints of Chest pain since 3 days Abdominal distension since 3 days Abdominal pain since 3 days and decreased urine output since 3days and not passed stools since 3days.
https://sreejaboga.blogspot.com/2020/11/is-online-e-log-book-to-discuss-our.html?m=1
Q1) Where are the different anatomical locations of the patient's problems and what are the different etiologic possibilities for them? Please chart out the sequence of events timeline between the manifestations of each of these problems and current outcomes.
A) The anatomical locations of the problems and their etiological possibilities :
The pain in the epigastrium could be because of MI, Gastritis, peptic ulcer etc.
There could be pancreatitis secondary to chronic alcohol consumption, gallstones, Hypertriglyceridemia, chronic smoking and high age.
In the Kidneys for Oliguria
There could be pre renal AKI possibly due to the fluid loss that's occurring because of the pancreatitis or it could also be tubular injury in the kidneys due to Sepsis.
The heart and lungs for SOB
The pancreatitis could cause pleural effusion by means of MODS
The AKI could lead to volume overload and heart failure which eventually leads to the development of shortness of breath as a symptom.
The decrease/difficulty in passing stools could be because of the pancreatitis causing paralytic ileus preventing normal bowel movement, or any intestinal obstruction, the former possibly due to any ischaemia or decreased blood supply or bacterial toxin induced.
Sequence of events :
Initially the patient had the complaints of the bow leg deformity which was congenital
He then gave a history of alcohol consumption and smoking for a chronic period of about 30 years.
He finally presented with the complaints of abdominal pain and distension, SOB, chest pain and decreased urine output since 3 days.
Outcomes after admission to the hospital :
at day 2 of admission the urine output increased and there was a decrease in the SOB and pedal oedema.
At day 3 the patient was in Altered sensorium
At day 4 dialysis was done for the patient
At day 5 the patient gave complaints of bilious vomiting
At day 6 Dialysis was again done for the patient.
At day 8 there was decrease in the abdominal pain and vomitings
The patient has now been put on a schedule for hemodialysis due to his Renal failure.
Q2) What are the pharmacological and non pharmacological interventions used in the management of this patient and what are the efficacy of each one of them?
A2) The non pharmacological interventions used in the treatment of the patient are :
1. keeping the patient Nil by oral
2. Placing a ryles tube
3. And oxygenating the patient as and when required.
The pharmacological interventions used in this patient are :
1. First and foremost replacing fluids intravenously seems to be the way forward as there is increased vascular permeability seen in pancreatitis which leads to decreased plasma volume as the days progress. This can lead to Shock and possible renal failure and subsequent decrease in the microvascular blood supply to the pancreas may lead to pancreatic ischemia and necrosis.
2. Antibiotics although prescribed here actually play no role for obvious reasons in pancreatitis that isn't caused by infectious agents.
Antibiotics haven't been proven to be efficacious in patients with acute pancreatitis as its an inflammatory process.
The following article gives us some insight regarding the same :
P - 1097 with Severe Acute Panceatitis who were admitted to the study institutions between January 1, 2009, and December 31, 2013, a retrospective cohort study of all consecutive patients.
3. Tramadol has been given to the patient for the management of pain.
4. Zofer has been given to the patient to reduce the episodes of vomitings.
5. Pantop has been given to this patient to prevent excess acidic environment and gastritis and further damage to the pancreas.
6.Injections Of Furosemide were given to reduce the fluid overload in the patient.
7. Patient was nebulized in order to provide relief for SOB and reduce the incidence of wheeze and crepts.
Qa1) Added 17/11/2020 Mention the optimal diagnostic interventions in the patient done and that you may further order in a low resource setting to fathom the etiologic possibilities.
Aa1) I would order for Routines such as hemogram to look for sepsis, RFT to assess the serum creatinine and blood urea levels as the patient was in renal failure, ABG shows metabolic acidosis due to renal failure
The FLP shows hypertriglyceridemia
I would order for a USG Abdomen to look for the cause of abdominal pain.
Right upper limb carotid doppler was done as the patient had right upper limb venous stasis and had feeble pulse which revealed complete occlusion of right radial & ulnar artery, and right distal large plaque extending to proximal ICA causing 50-70% stenosis
I would want to order for a CECT abdomen as it would aid in diagnosing the presence of any pancreatic necrosis, any pseudocysts, any calcifications etc. and that would aid in changing in our treatment strategy.
Case 2 :
A 55 year old male, shepherd by occupation, presented to the OPD with the chief complaints of fever (on and off), loss of appetite, headache, body pains, generalized weakness since 2 months, cough since 2 weeks and vomitings and pain abdomen since 2 days.
https://aakansharaj.blogspot.
Q1) Where are the different anatomical locations of the patient's problems and what are the different etiologic possibilities for them? Please chart out the sequence of events timeline between the manifestations of each of these problems and current outcomes.
A1) Anatomical locations of the patients problems and their etiological possibilities :
The bone marrow is involved and the possible etiological cause could be Multiple Myeloma.
The kidney is involved and the possible cause of the patients problems could be AKI induced due to the myeloma.
The lungs are involved due to tuberculosis and it makes the patient more susceptible to other infections.
Hematologically anemia is seen and it is mostly due to the Multiple myeloma and its pathophysiology.
The following is the timeline of events :
Initially he started with Alcohol consumption and tobacco smoking for a period of about 35 years. Then he stopped binging on alcohol about 4 yrs back.
Then about 1.5 yrs back when he had complaints of fever, generalized weakness and anemia, about 2 units of blood were transfused into him .
4 months back he allegedly stopped smoking.
He's been complaining of low grade fever, generalized weakness, headache, neck pain, loss of appetite and weight loss since the last 2 months.
He's been having complaints of cough and SOB since the last 2 weeks.
Finally he's complained of episodes of vomitings and pain abdomen since the last 2 days before admission in the hospital.
Final outcome was that after the prescribed treatment, the patient felt relief from his symptoms and was referred to an oncologist in view of further management of his condition.
Q2) What are the pharmacological and non pharmacological interventions used in the management of this patient and what are the efficacy of each one of them?
A2) Antibiotics were given to this patient for his underlying infection probably suspecting an atypical pneumonia.
ATT was given for his TB
SEVELAMER was given to cure his hyperphosphatemia
FEBUXOSTAT was given in view of his hyperuricemia.
Finally Prbc transfusion was done to correct his anemia.
CASE 3 :
51
Year old man with complaints of B/L pitting pedal edema from 5 to
6months,abdominal distension from 2 to 3 days,SOB from 3days.
nithishaavula.blogspot.com/
Q1) Where are the different anatomical locations of the patient's problems and what are the different etiologic possibilities for them? Please chart out the sequence of events timeline between the manifestations of each of these problems and current outcomes.
A1) The anatomical locations of the patients problems with the etiological possibilities are as follows :
His Heart is affected(HFrEF) mostly due to chronic DM and HTN which has probably lead to microvascular dysfunction subsequently leading to the heart failure.
the pedal oedema, SOB etc could also be due to Renal failure or hypoalbuminemia.
The Seizures were mostly due to the right frontal lobe infarct. the stroke would most probably be caused by the AF.
The following is the sequence of events that lead upto the current time period were the patient presented with the complaints :
He initally started chewing tobacco about 40 yrs back
Then 10 yrs back he started consuming alcohol. DM was diagnosed 7 yrs back and HTN was diagnosed about 5 yrs back.
His 1st episode of GTCS was about 3yrs back and he also suffered from AF with HFpEF then
his 2nd episode of GTCS was 2 yrs back.
He suffered from HFrEF and anasarca 1 yr back which then subsided with medication
He gradually developed pedal oedema 6 months back and now he he presented to the hospital with the complaints of increase in the pedal oedema, abdominal distension, SOb and decreased urine output since the last 3 days.
Current outcome was that his symptoms were relieved with the help of medication and he was discharged.
Q2) What are the pharmacological and non pharmacological interventions used in the management of this patient and what are the efficacy of each one of them?
A2) PHARMACOLOGICAL INTERVENTIONS
1.LASIX : Mortality: 3 placebo-controlled trials (n=221) reported data; the OR was 0.25 (95% confidence interval, CI: 0.07, 0.84, P=0.03), representing an absolute risk reduction of 8% in mortality in patients treated with diuretics compared to placebo.
Worsening of heart failure: 4 placebo-controlled trials (n=448) and 4 active-controlled trials (n=177) reported data. The OR was 0.31 (95% CI: 0.15, 0.62, P=0.001) for the placebo-controlled trials and 0.34 (95% CI:0.10, 1.21, P=0.10) for the active-controlled trials.
https://www.ncbi.nlm.nih.gov/books/NBK69174/
2.METAPROLOL : For HTN
3.ENALAPRIL : For HTN & as afterload reducing agent for heart failure
4.PHENYTOIN : For seizures
5.H.ACTRAPID INSULIN : For DM
6.PREGABALIN : For neuropathy
7. tab ECOSPIRIN to prevent stroke
NON PHARMACOLOGIC :
1.SALT AND FLUID RESTRICTION
https://pubmed.ncbi.nlm.nih.gov/23787719/
Individualized salt and fluid restriction can improve signs and symptoms of CHF with no negative effects on thirst, appetite, or QoL in patients with moderate to severe CHF and previous signs of fluid retention.
CASE 4 :
31 yr old man with B/L pedal edema with scrotal and penile swelling since 2 months
https://nairaditya97.blogspot.
Q1) Where are the different anatomical locations of the patient's problems and what are the different etiologic possibilities for them? Please chart out the sequence of events timeline between the manifestations of each of these problems and current outcomes.
A1) The anatomical locations of the patients problems and the etiological possibilities for them :
The Pedal oedema , SOB, scrotal and penile swelling is mostly due to heart failure and gauging from his history it seems to be caused by chronic alcoholism causing wet beri beri.
The Axonal Sensory neuropathy can be said to be caused by the toxic effects of alcohol on the nerves and their myelin sheath due to free radical injury etc .
The sequence of events in the patients that lead to his present presentation :
Initially the patient started consuming alcohol and khaini etc about 3 yrs back.
Then about 1 yr back he complained of pins and needles.
The bounding palpitations were felt by him about 8 months back with complaints of PND about 3 months back and pedal oedema and SOB about 2 months back.
Final outcome was that he was completely relieved of his symptoms with medical management.
Q2) What are the pharmacological and non pharmacological interventions used in the management of this patient and what are the efficacy of each one of them?
A2) PHARMACOLOGICAL INTERVENTIONS :
1.LASIX : Mortality: 3 placebo-controlled trials (n=221) reported data; the OR was 0.25 (95% confidence interval, CI: 0.07, 0.84, P=0.03), representing an absolute risk reduction of 8% in mortality in patients treated with diuretics compared to placebo.
Worsening of heart failure: 4 placebo-controlled trials (n=448) and 4 active-controlled trials (n=177) reported data. The OR was 0.31 (95% CI: 0.15, 0.62, P=0.001) for the placebo-controlled trials and 0.34 (95% CI:0.10, 1.21, P=0.10) for the active-controlled trials.
https://www.ncbi.nlm.nih.gov/books/NBK69174/
2.THIAMINE : In the study by Schoenenberger and colleagues (n=9), patients who took thiamine had 3.30% (95% confidence interval [CI]: 0.63%, 5.97%) greater LVEF compared to those on placebo.
Likewise, Shimon et al reported that thiamine resulted in 2.20% greater LVEF than the placebo group (n=29), although the extra improvement was not significant (95% CI: −18.97, 23.37%).
In our meta analysis, thiamine supplementation resulted in a significantly improved net change in LVEF (3.28%, 95% CI: 0.64%, 5.93%) compared with placebo.
3.TELMISARTAN : It was used to reduce the afterload that would aid his heart that was in a state of failure.
NON PHARMACOLOGIC :
1.SALT AND FLUID RESTRICTION :
https://pubmed.ncbi.nlm.nih.gov/23787719/
Individualized salt and fluid restriction can improve signs and symptoms of CHF with no negative effects on thirst, appetite, or QoL in patients with moderate to severe CHF and previous signs of fluid retention.
