GENERAL MEDICINE INTERNAL ASSESSMENT.

1) A 55 year old man with Recurrent Focal Seizures 

Detailedpatient case report

here: http://ushaindurthi.blogspot.com/2020/11/55-year-old-male-with-complaints-of.html

1.What is the problem representation of this patient and what could be the anatomical site of lesion ?


A 55 year old male construction worker with T2DM who is a chronic alcoholic & smoker came with c/o weakness of right upper limb with involuntary movements of both right UL & LL secondary to ? right temporal lobe epileptogenic focus.


2. Why are subcortical internal capsular infarcts more common that cortical infarcts?


subcortical infarcts are caused by occlusion of a penetrating artery from a large cerebral artery, most commonly from the Circle of Willis. These penetrating arteries arise at sharp angles from major vessels and are thus, anatomically prone to constriction and occlusion. 
So subcortical infarcts are more common than cortical infarcts.

3. What is the pathogenesis involved in cerebral infarct related seizures?








4. What is your take on the ecg? And do you agree with the treating team on starting the patient on Enoxaparin?


Ventricular ectopics seen
Left axis deviation +
ST depressions noted in precordial leads V1 to V6
NSTEMI

Yes , i agree with the treating team on starting the patient on Enoxaparin.


5. Which AED would you prefer?

As it is focal seizure i would prefer carbamazepine
And lorazepam / diazepam to prevent the conversion of focal seizure to GTCS



Please provide studies on  efficacies of each of the treatment given to this patient.






Question 2) 55 year old man with Recurrent hypoglycemia

Patient details in the intern logged online case report here: http://manojkumar1008.blogspot.com/2020/12/shortness-of-breath-with-high-sugars.html

Questions:

1. What is the problem representation for this patient? 

 A 55 year old male with T2DM & HTN since 10 years.     c/o exertional dyspnea and cough since 3 days and sudden onset giddiness and profuse sweating secondary to OHA induced hypoglycemia.

2. What is the cause for his recurrent hypoglycemia? And how would you evaluate? 


3. What is the cause for his Dyspnea? What is the reason for his albumin loss?

DYSPNEA:
Obesity increases the work of breathing because of the reductions in both chest wall compliance and respiratory muscle strength.
Excess metabolically active adipose tissue plus increased workload on supportive respiratory muscle leads to increased CO2 production (hypercapnia) and increased O2 consumption (hypoxia).
Pulmonary function abnormalities resulting from obesity

4. What is the pathogenesis involved in hypoglycemia ?


5. Do you agree with the treating team on starting the patient on antibiotics? And why? Mention the efficacies for the treatment given.

Yes i agree with the treating team starting antibiotics as his renal parameters are deranged and he may be having AKI (?renal)
CUE / urine cultures / USG abdomen are not available to support it as renal cause of AKI
Spot urine sodium is high may be secondary to ATN

3)


A. 41 year old man with Polyarthralgia

Case details here: https://mahathireddybandari.blogspot.com/2020/11/41m-with-chest-pain-and-joint-pains.html?m=1

1. How would you evaluate further this patient with Polyarthralgia?


2. What is the pathogenesis involved in RA?


https://www.google.com/url?sa=t&source=web&rct=j&url=https://www.hopkinsarthritis.org/arthritis-info/rheumatoid-arthritis/ra-pathophysiology-2/&ved=2ahUKEwjI-J_ZrObtAhWF7nMBHYHDCy4QFjAXegQIKRAB&usg=AOvVaw27b8Rt0lo57Q6Rpp6UjASB&cshid=1608803720629

3. What are the treatment regimens for a patient with RA and their efficacies?

Treatment options include medications, reduction of joint stress, physical and occupational therapy, and surgical intervention

Pharmacological Strategies

There are three general classes of drugs commonly used in the treatment of rheumatoid arthritis: non-steroidal anti-inflammatory agents (NSAIDs), corticosteroids, and disease modifying anti-rheumatic drugs (DMARDs)

Non-steroidal Anti-inflammatory Agents (NSAIDs)

The major effect of these agents is to reduce acute inflammation thereby decreasing pain and improving function

Newer "second-line" drugs (DMARDs)


B. Biologic" medicines

75 year old woman with post operative hepatitis following blood transfusion

Case details here: https://bandaru17jyothsna.blogspot.com/2020/11/this-is-online-e-log-book-to-discuss.html


1.What are your differentials for this patient and how would you evaluate?

Post transfusion delayed hemolytic reaction

Evaluation:

ABO and Rh compatability
coombs testing 
antibody panel testing


-Transfusion related acute hepatic injury (TRAHI)
-Post transfusion hepatitis
-Ischemic hepatitis

2. What would be your treatment approach? Do you agree with the treatment provided by the treating team and why? What are their efficacies?

Symptomatic management
I agree with the treatment provided by the treating team 
  • Lasix & Nebulization : For wheezing and crepts
  • Lactulose : To prevent hepatic encephalopathy 
  • Zofer : For vomitings
  • Pantop : To prevent gastritis.

4) 60 year woman with Uncontrolled sugars

http://manojkumar1008.blogspot.com/2020/12/60-yr-old-female-with-uncontrolled.html

1. What is the problem representation of this patient?

 60 year old female with T2DM & HTN since 2 years c/o pricking type of chest pain since 4 days and uncontrolled sugars secondary to ? right upper lobe pneumonic consolidation with sepsis.


2. What are the factors contributing to her uncontrolled blood sugars?


3. What are the chest xray findings?

Plain radiograph of chest , frontal view

Trachea shifted towards right
Hyperdense area noted in the right upper lobe 
(consolidation)

Peripheral pulmonary vasculature is normal
Heart is central in position
Cardiac size normal
The domes of diaphragm are normal in position and smooth outline
Visualized bones and soft tissue appear normal.


4. What do you think is the cause for her hypoalbuminaemia? How would you approach it?

  • Inflammation (acute phase reactant)
  • Malnutrition
  • Albuminuria (protein losing nephropathy)
Approach to hypoalbuminemia

5. Comment on the treatment given along with each of their efficacies with supportive evidence.

  • Piptaz & clarithromycin : for his right upper lobe pneumonic consolidation and sepsis
  • Egg white & protien powder : for hypoalbuminemia
  • Lactulose : for constipation
  • Actrapid / Mixtard : for hyperglycemia
  • Tramadol : for pain management
  • Pantop : to prevent gastritis
  • Zofer : to prevent vomitings.

5) 56 year old man with Decompensated liver disease

Case report here:  https://appalaaishwaryareddy.blogspot.com/2020/11/56year-old-male-with-decompensated.html

1. What is the anatomical and pathological localization of the problem?

Liver : Chronic liver disease (cirrhosis) secondary to HBV

Kidney : AKI on CKD (Hepatorenal syndrome) , Hyperkalemia

GI : GAVE , portal hypertensive gastropathy

Lung : pneumonia , pleural effusion

2. How do you approach and evaluate this patient with Hepatitis B?



3. What is the pathogenesis of the illness due to Hepatitis B?


4. Is it necessary to have a separate haemodialysis set up for hepatits B patients and why?

Yes , separate machines must be used for patients known to be infected with HBV (or at high risk of new HBV infection). A machine that has been used for patients infected with HBV can be used again for non-infected patients only after it has been decontaminated using a regime deemed effective against HBV because of increased risk of transmission due to contamination.

5. What are the efficacies of each treatment given to this patient? Describe the efficacies with supportive RCT evidence. 

Yes , separate machines must be used for patients known to be infected with HBV (or at high risk of new HBV infection). A machine that has been used for patients infected with HBV can be used again for non-infected patients only after it has been decontaminated using a regime deemed effective against HBV because of increased risk of transmission due to contamination.

6) 58 year old man with Dementia

Case report details: http://jabeenahmed300.blogspot.com/2020/12/this-is-online-e-log-book-to-discuss.html

1. What is the problem representation of this patient?


A 58 year old weaver occasional alcoholic c/o slurring of speech , deviation of mouth to right side associated with drooling of saliva , food particles and water predominantly from left angle of mouth and smacking of lips since 6 months.

Urinary urge incontinence since 6 months.
Forgetfulness since 3 months.
He has delayed response to commands.
Dysphagia to both solids and liquids since 10 days.
K/c/o CVA 3 years back and now he was diagnosed as neuro degenerative disease - Alzheimer's (? Vascular - post stroke sequale.


2. How would you evaluate further this  patient with Dementia?



3. Do you think his dementia could be explained by chronic infarcts?

Yes 



ABBREVIATIONS

AD : Alzheimer’s disease
CH : cerebral haemorrhage
CVD : cerebrovascular disease
MI : myocardial infarction
MID : multi-infarct dementia
LVD : large vessel disease
SIVD : subcortical ischaemic vascular dementia
SVD : small vessel disease
VCI : vascular cognitive impairment
VaD : vascular dementia

4. What is the likely pathogenesis of this patient's dementia?

Aβ plaque formation are key hallmarks of the AD brain. Specialized pro-resolving mediators and strategies aimed at boosting resolution such as using omega-3 polyunsaturated fatty acid exert differential effects on these targets and provide anti-inflammatory and pro-cognitive effects in neuroinflammation/degeneration

5. Are you aware of pharmacological and non pharmacological interventions to treat such a patient and what are their known efficacies based on RCT evidence?

PHARMACOLOGIC:

Cholinesterase inhibitors:
  • Donepezil
  • Rivastigmine
  • Galantamine

NMDA antagonist:
  • Memantine
NON PHARMACOLOGIC:
  • Counselling the patient and care givers
  • Geriatric care
  • Cognitive / emotion oriented interventions
  • Sensory stimulation interventions
  • Behaviour management techniques
  • Efficacy:

7) 22 year old man with seizures

Case report here http://geethagugloth.blogspot.com/2020/12/a-22-year-old-with-seizures.html

1. What is the problem representation of this patient ? What is the anatomic and pathologic localization in view of the clinical and radiological findings? 


A 22 year old delivery boy chronic alcoholic and tobacco chewer c/o on & off fever since 1 year , involuntary weight loss since 6 months , headache since 2 months , 4 - 5 episodes of involuntary stiffening of both UL & LL with 5 min LOC 1 week before the day of admission.

Brain - multiple ring enhancing lesions in right cerebellum ? Tuberculoma
RVD positive

2. What the your differentials to his ring enhancing lesions?


Bacterial
Pyogenic abscess
Tuberculoma and tuberculous abscess Mycobacterium avium-intracellulare infection Syphilis
Listeriosis

Fungal
Nocardiosis
Actinoimycosis 
Rhodococcosis 
Zygomycosis
Histoplasmosis
Coccidioidomycosis
Aspergillosis
Mucormycosis
Paracoccidioidomycosis
Cryptococcosis

Parasitic
Neurocysticercosis
Toxoplasmosis
Amoebic brain abscess
Echinococcosis
Cerebral sparganosis
Chagas' disease

Neoplastic
Metastases
Primary brain tumor
Primary CNS lymphoma

Inflammatory and demyelinating
Multiple sclerosis
Acute disseminated encephalomyelitis
Sarcoidosis
Neuro-Behcet.s disease
Whipple's disease
Systemic lupus erythematosus

3. What is "immune reconstitution inflammatory syndrome IRIS and how was this patient's treatment modified to avoid the possibility of his developing it?

A paradoxical clinical worsening of a known condition or the appearance of a new condition after initiating anti retroviral therapy (ART) therapy in HIV-infected patients resulting from restored immunity to specific infectious or non-infectious antigens is defined as immune reconstitution inflammatory syndrome (IRIS).


 8) Please mention your individual learning experiences from this month.

  • Hypertensive urgency management
  • Status epilepticus management
  • Ballismus & chorea
  • Alcohol withdrawal seizures
  • ASD & VSD in 2D ECHO
  • Phenytoin toxicity
  • Essential tremors
  • How to withdraw ABG& how to evaluate ABG
  • Cardio-pulmonory-resuscitation(CPR)
  • Intubation steps
  • How to assist central line.


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