MEDICINE BLENDED ASSIGNMENT ( MAY)

May 30, 2021

G.Sahithi Reddy medicine Assignment

MEDICINE BLENDED ASSIGNMENT

May 24,2021

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, investigation and diagnosis and come up with the treatment plan.

This is the link of questions asked regarding the cases:

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

Below are my answers to the medicine assignment based on my comprehension of the cases

Pulmonology

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

Question number-1

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?

Evolution of symptomology:

20 yrs back-First episode of shortness of breath(lasted for 1 week during January)and continued in the same pattern for 7 years

↓

12 years back-Episode lasted for 20 days and continued in the same pattern till 30 days back

↓

Latest episode- lasted for 30 days and not getting relieved on medication

↓

Other symptoms

5 yrs ago-Anaemia

1 month back-Generalised weakness

20 days ago- Hypertension

15 days ago- pitting type of pedal edema and facial puffiness

Anatomical localization of the problem:

Bronchi and bronchioles of the lung

Primary etiology :

The symptoms are probably due to the inhalation of Paddy dust

Paddy dust is biologically composed of

plant material

fungi: of genus epicocum, fusarium

parts of insects: House dust mites and storage mites

bacteria

soil

Rice dust enters human airway(extrinsic antigen)

↓

It triggers and stimulate the plasma cells and lymphoid tissue to produce IgE

↓

IgE bind to mast cell and release Histamine and Bradykinin

↓

These narrow the respirator tract and increase of mucus production

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

1.Head and elevation: Significantly increases global and regional end-expiratory lung volume. It has also been shown to improve oxygenation and hemodynamic performance.

2.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, Euophagus 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 easily. Your doctor or pharmacist will guide you on how to use nebulisers properly. You should take Budecort regularly as advised by your doctor for effective control of your asthma

9. Tab pulmoclear

It contains a combination of two medicines, Acebrophylline and Acetylcysteine. They belong to the class of bronchodilators and mucolytics, respectively. It is used for relieving the symptoms of coughing, wheezing, congestion and blockage in the airways in a condition called chronic obstructive pulmonary disease (COPD).

10) Chest physiotherapy

It is a term used for a group of treatments designed to improve respiratory efficiency, promote expansion of the lungs, strengthen respiratory muscles, and eliminate secretions from the respiratory system.It includes postural drainage, chest percussion, chest vibration, turning, deep breathing exercises, and coughing.

11)Inj HAI SC

Human Actrapid 40IU/ml Solution for Injection is a short-acting insulin used to treat type 1 and type 2 diabetes mellitus. It is used together with a healthy diet and regular exercise to control blood sugar levels after meals. This helps to prevent serious complications of diabetes like kidney damage and blindness.

12) Inj thiamine

To treat or prevent thiamine(B1) insufficiency

13)Vitals charting

This allow for continuous monitoring of a patient, with medical staff being continuously informed of the changes in general condition of a patient.

14)I/O chart

Urine input/output chart

This chart (also known as a frequency-volume chart or bladder diary) is used to assess how much fluid you drink, to measure your urine volume, to record how often you pass urine over 24 hours and to show any episodes of incontinence (leakage)

15) 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 complications

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

Respiratory infection, being responsible for approximately half of COPD exacerbations. Common bacterial pathogens of acute exacerbations include Haemophilus influenzae, Streptococcus pneumoniae and Moraxella catarrhalis.[7]Less common bacterial pathogens include Chlamydia pneumoniae and MRSA.

Allergens, e.g., pollens, wood or cigarette smoke, pollution[5]

Toxins, including a variety of different chemicals[5]

Air pollution[citation needed]

Failing to follow a drug therapy program, e.g. improper use of an inhaler

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

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?

The distribution of electrolyte disturbances in COPD group (total 58.53%) was found as follows: hypokalemia in 20%, hyponatremia in 13.33%, hypomagnesemia in 6.66%, hypochloremia in 3.33%, and combined disturbances in 15%.

Activation of the renin-angiotensin-aldosterone system and inappropriately elevated plasma arginine vasopressin in COPD may aggravate the electrolyte imbalance during acute exacerbation of COPD

This patient has Hyponatremia and Hypochloremia according to the reports

Hyponatremia in patients with COPD developed secondary to many reasons, such as development or worsening of hypoxia, hypercapnia, and respiratory acidosis, and right-side heart failure with development of lower limb edema, renal insufficiency, use of diuretics

respiratory acidosis with metabolic alkalosis (owing to renal compensation) in patients with COPD with chronic hypercapnia is the usual cause of hypochloremia in those patients.

Neurology

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

Question number -2A

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?

Timeline of patient symptomatology:

2009 (12 years ago): Started drinking alcohol

2019 (2 years ago): Diagnosed with Diabetes Mellitus, prescribed oral hypoglycemics

2020 (1 year ago): Has an episode of seizures (most likely GTCS)

January 2021 (4months ago): Has another seizure episode (most likely GTCS)- following cessation of alcohol for 24 hours. Starts drinking again after seizure subsides

Monday, May 10, 2021: Last alcohol intake, around 1 bottle. Starts having general body pains at night.

Tuesday, May 11, 2021: Decreased food intake. Starts talking and laughing to himself. Unable to lift himself off the bed, help required.

Conscious, but non coherent. Disoriented to time, person, place.

Goes to an RMP the same day- is prescribed IV fluids and asked to visit a hospital

Saturday, May 15, 2021: Is admitted to a tertiary care hospital for alcohol withdrawal symptoms, and is treated for the same.

Anatomical localisation of problem: The most probable location in the brain is the hippocampus and frontal lobe.

Primary etiology of patient's problem: Chronic Alcoholism

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

IVF NS and RL 150ml per hour

aim of lowering alcohol levels and its metabolites, reducing its neuro-depressive effects, and making patents spending less time in the ED.

Thiamine

Thiamine has no effect on the symptoms or signs of alcohol withdrawal or on the incidence of seizures or DTs. Routine use of thiamine is recommended 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

are used to treat alcoholism and alcohol withdrawal symptoms

Lorazepam is used by rehab facilities across the nation to help patients overcome an AUD

The drug helps alleviate anxiety associated with alcohol withdrawal. Treatment providers may also prescribe it to reduce the risk of seizures.

Pregabalin

Pregabalin is a high-affinity α2δ voltage-gated calcium channel subunit ligand [23, 24], indicated in different countries for the treatment of neuropathic pain associated with a variety of conditions, fibromyalgia, generalized anxiety disorder (GAD), and as adjunctive therapy for adults with partial-onset seizures

HAI

Lactulose

Lactulose is helpful in patients with an acute onset of severe encephalopathy symptoms and in patients with milder, chronic symptoms. This nonabsorbable disaccharide stimulates the passage of ammonia from tissues into the gut lumen and inhibits intestinal ammonia production.

Kcl KCL in NS is a prescription medicine used to treat the symptoms of Hypokalemia, prophylaxisfor Hypokalemia

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?

A possible cause for this is due to a phenomenon known as kindling. [1]

In kindling, repeated attempted alcohol detoxification leads to an increased severity of the withdrawal syndrome. Patients with previous withdrawal symptoms are more likely to have more medically complicated withdrawal symptoms with time.

eg, in this patient

Chronic alcohol use and kindling together leads to permanent alteration in GABA receptors, leading to downregulation of GABA. This in turn leads to inhibition of inhibitory neurotransmitter GABA, hence leading to seizures (hyperactivity).

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

One of the differential diagnoses for altered sensorium following chronic alcoholism is Wernicke-Korsakoff Syndrome, caused by deficiency of thiamine (B1). To either treat or rule this differential out, thiamine is given.

Thiamine is necessary to provide energy to the CNS, helps in conduction of nerve signals.

Hence, deficiency leads to confusion and ataxia, both of which are present in this patient.

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

As the urea levels are very high, it denotes an acute onset- Acute Renal Failure.

As high serum creatinine, and urea levels are present, denotes that reabsorption from tubules is taking place- therefore the primary cause is prerenal, most probably due to generalised dehydration.

A slightly high FENa level also denotes that tubular necrosis is occurring to some degree, hence the Prerenal AKI (mostly due to dehydration) is in turn leading to Acute Tubular Necrosis (ATN).

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

Possible causes:

a. Increased oxidative stress and inflammation, leading to hemolysis of the RBCs

b. Decreased bone marrow production of RBCs, due to EPO deficiency owing to kidney failure

c. Loss of blood through chronic foot ulcer

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

Yes, as alcoholism itself can cause peripheral neuropathy (alcoholic neuropathy), which along with Diabetic neuropathy, can lead to a non-healing foot ulcer.

Question number -2B

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

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?

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?

Vertin Tablet is used to prevent and treat a disorder of the inner ear known as Ménière's disease. The symptoms include dizziness (vertigo), ringing in the ears (tinnitus), and loss of hearing, probably caused by fluid in the ear. This medicine helps relieve the symptoms by reducing the amount of fluid.

Zofer anti-emetics' primarily used in the prevention of vomiting (being sick) and nausea (feeling sick) that usually occur after cancer chemotherapy, radiation treatment or surgery.

Ecosporin commonly used for the diagnosis or treatment of Headache, migraine, fever, sore throat, 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 is a type of medicine called an antiplatelet: it reduces the risk of blood clots forming within your circulatory system or blood vessels.

Mvt Methylcobalamin is used in vitamin B12 deficiency.

Methylcobalamin is a form of vitamin B12 that restores its level in the body thereby helping in treating certain anemias and nerve problems.

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

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?

Ischemic stroke is the most common type of stroke. It is caused by a blood clot blocking the flow of blood and oxygen from reaching the brain.

A hemorrhagic stroke occurs either when an aneurysm bursts, or a weakened blood vessel leaks. The result is bleeding either inside the brain, causing an intracerebral hemorrhage, or, less commonly, bleeding between the brain and the tissue covering it, causing a so-called subarachnoid hemorrhage.

heavy drinkers were about 1.6 times more likely to suffer from intracerebral hemorrhage and 1.8 times more likely to suffer from subarachnoid hemorrhage. The association between heavy alcohol consumption and these two types of stroke was stronger than that for ischemic stroke

Therefore, even if moderate drinking may have a beneficial effect by lowering the risk of ischemic stroke, the disadvantages might outweigh the benefits.

The adverse effect of alcohol consumption on blood pressure – a major risk factor for stroke – may increase the risk of hemorrhagic stroke and outweigh any potential benefit

Question number - 2C

http://bejugamomnivasguptha.blogspot.com/2021/05/a-45-years-old-female-patient-with.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?

10 years back-Paralysis of both upper and lower limbs bilateral

1 year back-Right and left paresis due to hypokalemia

8 months backSwelling over legs

7 months back - blood infection

2 months back- neck pain

6 days back- pain along left upper limb

5 days back- chest pain, Difficulty in breathing and was able to feel her own heart beat

Anatomical 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?

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 diuretics

Heart failure

Hypertension

Low BMI [3]

Eating disorder and alcoholism: low intake of potassium

Diarrhea, cushing syndrome, a

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

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.

Question number -2D

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

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

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?

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)

Question number -2E

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

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

The patient has minor unattended head injuries in the past 1 yr. Accoding 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 ?

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 alcholic. 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

Question number -2F

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

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

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?

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?

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?

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??

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.

Question number -2G

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

1.What is myelopathy hand?

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?

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?

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

Question number -2H

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

1. What can be the cause of her condition?

Cortical venous sinus thrombosis

2.what are the risk factors for cortical vein thrombosis?

Sickle cell anemia

Beta thalassemia major

Chronic hemolytic anemia

Iron deficiency

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

Reoccurence could be the persistence of excitable foci, till the oedema resolves.

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

Venous thrombosis whether in cortical veins or in cortical sinus requires anticoagulation

Cardiology

Question number - 3A

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?

Ejection fraction (EF) is a measurement, expressed as a percentage, of how much blood the left ventricle pumps out with each contraction

Heart Failure with Reduced Ejection Fraction

Also called systolic heart failure, heart failure with reduced ejection fraction is the most common type of heart failure. It occurs when the left ventricle, the heart’s main pumping chamber, weakens and can’t pump blood effectively. This condition is also often called dilated cardiomyopathy.

Heart Failure with Preserved Ejection Fraction

In this condition, which is also called diastolic heart failure, the heart doesn’t relax properly, reducing the efficiency of the circulation of blood.

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

Pericardiocentesis is the most useful therapeutic procedure for the early management or diagnosis of large, symptomatic pericardial effusion and cardiac tamponade.

Since this patient has no Cardiac tamponade(life-threatening slow or rapid compression of the heart due to increasing pericardial fluid) there is no need for pericardiocentesis

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

cigarette smoke can also cause CVD by changing your blood chemistry1,2 and causing plaque—a waxy substance comprised of cholesterol, scar tissue, calcium, fat, and other material3—to build up in the arteries, the major blood vessels that carry blood from your heart to your body. This plaque buildup can lead to a disease called atherosclerosis.

Alcoholic cardiomyopathy is a form of heart disease caused by alcohol abuse. Long-term alcohol abuse weakens and thins the heart muscle, affecting its ability to pump blood

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

Low BP in HFrEF may have multiple origins such as low cardiac function, hypovolaemia (usually due to diuretics), treatment-related vasodilatation and altered vasoreactivity related to comorbidities such as diabetes.

Question number -3B

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

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

Alcoholic cardiomyopathy is a form of heart disease caused by alcohol abuse. Long-term alcohol abuse weakens and thins the heart muscle, affecting its ability to pump blood

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

High blood pressure can strain your heart, damage blood vessels, and increase your risk of heart attack

Diseases in the kidneys can affect the heart. It is common for people with chronic kidney disease or end-stage kidney disease to develop heart disease, including heart attack or heart failure.

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

In the general elderly population, anemia is caused by nutritional deficiencies (primarily iron), chronic inflammation/CKD, or unexplained anemia of the elderly (a hypoproliferative anemia with blunted erythropoietin response)

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

When high blood sugar destroys nerves, they do not regenerate; thus many patients with diabetes are increasingly less sensitive to pain in their limbs. With this loss of sensation, patients don't feel developing blisters, infections, or existing wound changes. That means that wound healing is complicated not only by the fact that patients don't feel wounds as they occur, but they also have no pain to alert them that a wound is getting worse or infected.

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

stage 1: defined as DCBD (dysglycemia-based chronic disease )insulin resistance;

stage 2: defined as DCBD prediabetes;

stage 3: defined as DCBD type 2 diabetes; and

stage 4: defined as DCBD vascular complications, including retinopathy, nephropathy or neuropathy, and/or type 2 diabetes-related microvascular events.

All these stages have been noted in this case

Question number-3C

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?

Imguinal hernia surgery 10 yrs ago( still has on and off pain)

Aggravated since 3 years

Facial puffiness on and off since 2 to 3 years

Hypertension since 1 year (presented as SOB of grade 2)

2 days back- Sob (initially grade 2, then progressed to grade 4) and anuria

Anatomical localisation

Heart (Atria)

Etiology

Loss of Atrial contraction and Left atrial dilatation causes stasis of blood in the LA and may lead to Thrombus formation in the Left Atrial Appendage. This predisposes patients to stroke and other forms of systemic embolism.

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

Dobutamine injection is indicated when parenteral therapy is necessary for inotropicsupport in the short-term treatment of adults with cardiac decompensation due to depressed contractility resulting either from organic heart disease or from cardiac surgical procedures.In patients who have atrial fibrillation with rapid ventricular response, a digitalis preparation should be used prior to institution of therapy with dobutamine hydrochloride

Digoxin a medication used to treat various heart conditions.[4] Most frequently it is used for atrial fibrillation, atrial flutter, and heart failure

Heparin, also known as unfractionated heparin (UFH), is a medication and naturally occurring glycosaminoglycan.[3][4] As a medication it is used as an anticoagulant.[3] Specifically it is also used in the treatment of heart attacks and unstable angina

Carvedilol is used alone or together with other medicines to treat high blood pressure

Acitrom - Treatment and prevention of Blood clots

Cardivas 3.125 Tablet is a medicine used to treat high blood pressure, heart-related chest pain (angina), and heart failure. It works by relaxing the blood vessels, so blood can flow more easily to the heart.

Dytor 10 mg is used to reduce the swelling (edema) caused by too much water in the body in people who have heart failure, liver disease, or kidney disease. This medicine is also used to treat high blood pressure.

Pan D capsule is used to treat GERD (Gastrointestinal reflux disease), not responding to pantoprazole alone. It helps in relieving symptoms such as heartburn, chest discomfort or acidity.

Taxim-O 200 tablet is used for the bacterial infection

HAI SC

12) Inj thiamine

To treat or prevent thiamine(B1) insufficiency

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

Cardiorenal syndromes (CRS) describe concomitant bidirectional dysfunction of the heart and kidneys in which 1 organ initiates, perpetuates, and/or accelerates decline of the other. CRS are common in heart failure and universally portend worsened prognosis.

It is Type-4 CRS, also defined as chronic reno-cardiac disease, is characterized by cardiovascular involvement in patients affected by chronic kidney disease at any stage

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

Hypertension since 1 yr

Cardiorenal syndrome type 4

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

The partial thromboplastin time (PTT; also known as activated partial thromboplastin time (aPTT)) is a screening test that helps evaluate a person's ability to appropriately form blood clots. It measures the number of seconds it takes for a clot to form in a sample of blood after substances (reagents) are added. The PTT assesses the amount and the function of certain proteins in the blood called coagulation or clotting factors that are an important part of blood clot formation.

The INR is found using the results of the prothrombin time (PT) test. This measures the time it takes for your blood to clot. The INR is an international standard for the PT.

Question number - 3D

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

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?

TIMELINE OF EVENTS-

• Diabetes since 12 years - on medication

• Heart burn like episodes since an year- relieved without medication

• Diagnosed with pulmonary TB 7 months ago- completed full course of treatment, presently sputum negative.

• Hypertension since 6 months - on medication

• Shortness of breath since half an hour-SOB even at rest

Anatomical localisation - Cardiovascular system

Etiology: The patient is both Hypertensive and diabetic , both these conditions can cause

- Atherosclerosis: there is build up of fatty and fibrous material inside the wall of arteries.(PLAQUE)

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

Pharmacological interventions:

TAB MET XL 25 MG/STAT-contains Metoprolol as active ingredient

MOA: METOPROLOL is a cardiselective beta blocker

Beta blockers work by blocking the effects of the hormone epinephrine, also known as adrenaline. Beta blockers cause your heart to beat more slowly( negative chronotropic effect)

and with less force( negative inotropic effect). Beta blockers also help open up your veins and arteries to improve blood flow.

Indications: it is used to treat Angina, High blood pressure and to lower the risk of hear attacks .

EFFICACY STUDIES.

Patients were randomized to one of four treatment arms: placebo or ER metoprolol (0.2 mg/kg, 1.0 mg/kg, or 2.0 mg/kg). Data were analyzed on 140 intent-to-treat patients.

Results: mean baseline BP was 132/78 +/- 9/9 mmHg. Following 4 weeks of treatment, mean changes in sitting BP were: placebo = -1.9/-2.1 mmHg; ER metoprolol 0.2 mg/kg = -5.2/-3.1 mmHg; 1.0 mg/kg = -7.7/-4.9 mmHg; 2.0 mg/kg = -6.3/-7.5 mmHg. Compared with placebo, ER metoprolol significantly reduced systolic blood pressure (SBP) at the 1.0 and 2.0 mg/kg dose (P = .027 and P = .049, respectively), reduced diastolic blood pressure (DBP) at the 2.0 mg/kg dose (P = .017), and showed a statistically significant dose response relationship for the placebo-corrected change in DBP from baseline. There were no serious adverse events or adverse events requiring study drug discontinuation among patients receiving active therapy.

Non pharmacological intervention advised to this patient is: PERCUTANEOUS CORONARY INTERVENTION.

Percutaneous Coronary Intervention is a non-surgical procedure that uses a catheter (a thin flexible tube) to place a small structure called a stent to open up blood vessels in the heart that have been narrowed by plaque buildup ( atherosclerosis).

3) What are the indications and contraindications for PCI?

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?

Although PCI is generally a safe procedure , it might cause serious certain complications like

A)Bleeding

B) Blood vessel damage

C) Allergic reaction to the contrast dye used

D) Arrhythmias

E) Need for emergency coronary artery bypass grafting .

Because of all these complications it is better to avoid PCI in patients who do not require it.

⁃ OVER TESTING AND OVER TRAETMENT HAVE BECOME COMMMIN IN TODAY’S MEDICAL PRACTICE.

⁃ Research on overtesting and overtreatment is important as they are more harmful than useful.

Harms to patients

. Performing screening tests in patients with who at low risk for the disease which is being screened.

For example:Breast Cancer Screenings Can Cause More Harm Than Good in Women Who Are at Low Risk. A harmless lump or bump could incorrectly come up as cancer during routine breast screenings. This means that some women undergo surgery, chemotherapy or radiation for cancer that was never there in the first place.

.Overuse of imaging techniques such as X- RAYS AND CT SCANS as a part of routine investigations.

Overuse of imaging can lead to a diagnosis of a condition that would have otherwise remained irrelevant - OVERDIAGNOSIS.

Also the adverse effects due to this are more when compared to the benefits.

.Overdiagnosis through overtesting can psychologically harm the patient.

Hospitalizations[41] for those with chronic conditions who could be treated as outpatients[ can lead to economic burden and a feeling of isolation.

Harms to health care systems

The use of expensive technologies and machineries are causing burden on health care systems.

Question number-3E

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

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?

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?

Aspirin indications

Angina pectoris

Angina pectoris prophylaxis

Ankylosing spondylitis

Cardiovascular risk reduction

Colorectal cancer

Fever

Ischemic stroke

Ischemic stroke: Prophylaxis

Myocardial infarction

Myocardial infarction: Prophylaxis

Osteoarthritis

Pain

Revascularization procedures: Prophylaxis

Rheumatoid arthritis

Systemic lupus erythematosus

Atorvas

pain or burning when you urinate,

upper stomach pain,

weakness,

feeling tired,

loss of appetite,

dark urine,

Clopibb

peripheral vascular disease (blood circulation problems due to narrowing of blood vessels), recent heart attack or stroke, irregular heartbeats, and those who have undergone certain heart procedures like stenting. It is also used in combination with some other medicines for the treatment of heart attack and some types of heart-related chest pain (unstable angina).

HAI SC

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

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

Question number - 3F

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?

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?

Torsemide used to relieve abdominal distension.

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

IT IS THE TREATMENT FOR UTI

Rationale- Used for any bacterial infection.

Gastroenterology

Question number -4A

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

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?

1) ING. MEROPENAM ; TID for 7 days

* Meropenem ( broad spectrum Carbepenem ) an antibiotic.

2) ING. METROGYL 500 mg IV TID for 5 days

* inj. Metrogyl has METRONIDAZOLE

( Nitroimidazole drug ) an antibiotic

3) ING. AMIKACIN 500 mg IV BD for 5days

* It is an Aminoglycoside antibiotic

## Here all three of these (Inj. Meropenem, Inj. Metrogyl, Inj. Amikacin ) are used as antibiotics to control infection and ; to prevent septic complications of acute pancreatitis.

4) TPN ( Total Parenteral Nutrition )

* Method of feeding that by passes gastrointestinal tract

* Fluids are given to vein , it provides most of the nutrients body needs.

* TPN has proteins, carbohydrates, fats, vitamins, minerals.

5) IV NS / RL at the rate 12l ml per hour

* Given for fluid replacement ie., treat dehydration

6) ING. OCTREOTIDE 100 mg SC , BD

* It is a Somatostatin long acting analogue.

* It is used here to decrease exocrine secretion of pancreas and it also has anti- inflammatory & cytoprotective effects.

7) ING. PANTOP 40 mg IV , OD

* Inj. Pantop has PANTOPRAZOLE ( Proton Pump Inhibitor) used for its anti pancreatic secretory effect.

8) ING. THIAMINE 100 mg in 100 ml NS IV , TID

* It is B1 supplement.

* It is given here because; due to long fasting & TPN usage , body may develop B1 deficiency

* Wernicke encephalopathy secondary to B1 deficiency may be caused... so a prophylactic B1 supplemention is necessary.

9) ING. TRAMADOL in 100 ml NS IV , OD

* It is an opioid analgesic, given to releive pain

Question number -4B

4)https://nehaelogs.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?

Acute pancreatitis in its severe form is complicated by multiple organ system dysfunction, most importantly by pulmonary complications which include hypoxia, acute respiratory distress syndrome, atelectasis, and pleural effusion. The pathogenesis of some of the above complications is attributed to the production of noxious cytokines

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

Hyperglycemia develops rather often in the early phase of acute pancreatitis, mainly in patients with severe disease [1–3]. This hyperglycemia could thus be the result of a hyperglucagonemia secondary to stress or the result of decreased synthesis and release of insulin secondary to the damage of pancreatic β-cells [4–7].

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

Elevated liver enzymes in the setting of acute pancreatitis point toward choledocholithiasis as the cause, with an alanine aminotransferase greater than three times the upper limit of normal having a positive predictive value of 95% for gallstone pancreatitis

In heavy drinkers, serum GGT, AST, ALT, ferritin and albumin were all significantly higher than in moderate drinkers or abstainers

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

clinicians employ goal-directed fluid therapy with either normal saline or lactated Ringers, give timely analgesics and antiemetics, and replete electrolytes as needed. The current recommendations are also to initiate feeding trials within 24 hours of disease onset instead of keeping the patient nill per mouth (NPO). There are no clear indications for the type of diet, but typically small low-fat, soft or solid meals correlate with shorter hospital stays than starting a clear liquid diet with slow advancement to solid meals. Enteral feeds via a feeding tube are preferred to total parenteral nutrition in patients unable to tolerate PO

Question number -4C

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

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

Ruptured liver abscess

2) What was the cause of her death?

Spontaneous gas-forming pyogenic liver abscess (GFPLA) is a rare complication with a high fatality rate in spite of aggressive management. Clinical spectrum of GFPLA can mimic hollow viscus perforation as it usually accompanied by pneumoperitoneum and peritonitis.

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

NSAIDs rarely affect the liver

NSAIDs are absorbed completely and undergo negligible liver metabolism.

Nephrology

Question number - 5A

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

1. What could be the reason for his SOB ?

Since the patients creatinine levels are very high, functioning of the kidney is reduced. This causes for the accumulation of fluid in the lungs and thus causes SOB

2. Why does he have intermittent episodes of drowsiness ?

In healthy individuals, sleep is accompanied by a decrease in sympathetic activity and an increase in vagal tone that leads to a nocturnal dipping of blood pressure

In any kind of kidney related problem it exhibit sympatho-vagal imbalance due to baroreceptor reflex function impairment in which there is hyperactivity of the sympathetic nervous system and decreased vagal tone

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

Creatinine is a normal waste product that the body produces every day during muscle movements and when digesting meat.

When creatinine is very high it probabaly means that high waste product of muscle is being formed and this might result in fleshy mass like passage

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

Transylurethral resection of prostate (TURP)

Bladder injury

Bleeding

Blood in the urine after surgery

Electrolyte abnormalities

Infection

Loss of erections

Painful or difficult urination

Retrograde ejaculation (when ejaculate goes into the bladder and not out the penis)

Question number -5B

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

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

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 ?

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?

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.

Infectious Disease (HI virus, Mycobacteria, Gastroenterology, Pulmonology)

Question number -6A

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

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

The patient is a known case of Retroviral Disease but she was on her ART since 2 months. There might be a possible chance that her negligence to treat RVD is the cause of her Tracheo esophageal and also TB.

Physical finding

According to CECT there is a fistulous communication between left main bronchi and mid thoracic oesophagus few centimetres below carina

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

Immune reconstitution inflammatory syndrome (IRIS) is a condition seen in some cases of AIDS or immunosuppression, in which the immune system begins to recover, but then responds to a previously acquired opportunistic infection with an overwhelming inflammatory response that paradoxically makes the symptoms of infection worse. The suppression of CD4 T cells by HIV (or by immunosuppressive drugs) causes a decrease in the body's normal response to certain infections. Not only does this make it more difficult to fight the infection, it may mean that a level of infection that would normally produce symptoms is instead undetected (subclinical infection). If the CD4 count rapidly increases (due to effective treatment of HIV, or removal of other causes of immunosuppression), a sudden increase in the inflammatory response produces nonspecific symptomssuch as fever, and in some cases a worsening of damage to the infected tissue

reported to occur in 13%–45% of HIV-infected persons who start ART

Infectious disease and Hepatology

Question number -7A

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 ?

Like any other alcoholic drink, excessive toddy (8.1%)drinking can damage the liver.Even the alcohol content is less than that of wine, the patient has been drinking it since 30 years . Therefore it is the major predisposing factor

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

There can be various mechanisms by which toddy could influence EH virulence. The resident microbial flora in human colon is an important determinant of survival and virulence in EH. Alcohol consumption is known to induce intestinal bacterial dysbiosis, which may in turn alter the activity of EH. Undistilled local alcoholic beverages contain a large number of microorganisms that might have more propensity to cause intestinal dysbiosis. EH lacks mitochondria and obtains its energy from the fermentation of glucose. EH alcohol dehydrogenase 2 (EHADH2) is a key enzyme in this pathway7. Thus, expression of EHADH2 is required for the growth and survival of EH trophozoites in human.

alcohol suppresses the function of Kupffer cells in the liver, which has the important role of clearing the amoeba. This leads to pathogenic invasion leading abscess formation

3. Is liver abscess more common in right lobe ?

Right lobe is more significant part with more blood supply. Therefore liver abscess is more common

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

Large abscess more than 6cms

Left lobe abscess

Caudate love abscess

Abscess which is not responding to drugs

Question number - 7B

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

1) Cause of liver abcess in this patient ?

The patient is occasional toddy drinker which has high amount of Entamoeba histolytica. This causes liver abscess by suppressing the function of Kuffper cells.Therefore Toddy is most probable cause of Liver abscess in this patient

2) How do you approach this patient ?

Hematology:

*Common hematological finding being LEUCOCYTOSIS , indicating inflammation or infection.

* Anemia may be present , or not.

Chemistry:

* Elevated liver enzymes such as AST,ALP are noted .

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

INJECTION. ZOSTUM 1.5 gm IV BD (twice daily)

Zostum is a combination of drugs - SULBACTUM (pencillin) & CEFOPERAZONE(cephalosporin) [Antibiotic]: It is used here to treat if any bacterial cause ( since we can’t take the risk relying on only anti amoebic therapy)

* INJECTION. METROGYL 500mg IV TID ( thrice daily )

Metrogyl has the drug called METRONIDAZOLE[Antibiotic]: For amoebic cause

* INJECTION. OPTINEURIN 1amp in 100 ml NS( Nor

mal Saline) IV OD ( once daily)

Optineurin is a multivitamin drug { A combination of B1,B2, B3, B5,B6, B12 } given here as a supplement

* TAB. ULTRACET 1/2 QID( four times a day)

Ultracet is a combination of drugs - TRAMADOL(opiod analgesic) and ACETAMINOPHEN (analgesic and antipyretic) : Given for pain and fever

* TAB. DOLO 650 mg SOS (if needed) given for fever and pain

* Here ; due to medical therapy his symptoms subsided and clearly we can see it in usg reports ( liquefaction) meaning abcess responded to our medical therapy.

*And the patient was discharged on 10/5/21.

* We donot aspirate the pus since it is self resolving and aspiration is associated with several other complications.

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

Apart from serological examination which is positive in 94% of the cases..Further confirmation can be done by using Ultrasonography but these are not commonly used

Infectious disease (Mucormycosis, Ophthalmology, Otorhinolaryngology, Neurology)

Question number - 8

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

Anatomical localisation : Medial canthus of left , Oral cavity and hardpalate, left nasal cavity and left frontal & temporal lobes

Primary etiology

Mucormycetes, the group of fungi that cause mucormycosis, are present throughout the environment, particularly in soil and in association with decaying organic matter, such as leaves, compost piles, and animal dung. 1 They are more common in soil than in air, and in summer and fall than in winter or spring. 2-4 Most people come in contact with microscopic fungal spores every day, so it’s probably impossible to completely avoid coming in contact with mucormycetes. These fungi aren’t harmful to most people. However, for people who have weakened immune systems, breathing in mucormycete spores can cause an infection in the lungs or sinuses which can spread to other parts of the body.

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?

Itraconazole acts by inhibiting the fungal cytochrome P-450 dependent enzyme lanosterol 14-α-demethylase. When this enzyme is inhibited it blocks the conversion of lanosterol to ergosterol, which disrupts fungal cell membrane synthesis. Itraconazole exhibits fungistatic (slows the growth) activity against yeast-like fungi and fungicidal (kills the fungus) activity against Aspergillus spp.

Amphotericin B binds with ergosterol, a component of fungal cell membranes, forming pores that cause rapid leakage of monovalent ions (K+, Na+, H+ and Cl−) and subsequent fungal cell death

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

Low oxygen, diabetes, high iron levels, immunosuppression, as well as several other factors including prolonged hospitalisation with mechanical ventilators, creates an ideal milieu for contracting mucormycosis,

Contamination in pipes of the oxygen cylinders

unhygienic masks" and poorly ventilated rooms could be a contributing factor

history of exhibiting poor hygienic practices, including wearing unwashed masks for a long time.

irrational use of steroids

Mucormycosis is more common among people whose immunity has lowered due to COVID, diabetes, kidney disease, liver or cardiac disorders, age-related issues, or those on medication for auto-immune diseases like rheumatoid arthritis.