FEBRUARY BIMONTHLY ASSESSMENT
FEBRUARY BIMONTHLY EXAM
Questions:
Q.1) Please go through the patient data in the links below and answer the following questions:
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
More here: https://archanareddy07.blogspot.com/2021/02/50m-with-parkinsonism.html?m=1
Case presentation links:
https://youtu.be/kMrD662wRIQ
a). What is the problem representation of this patient and what is the anatomical localization for his current problem based on the clinical findings?
problem presentation:
involuntary movements of bilateral upper limbs
frequent episodes of fatigue since one year
thin stream of urine with bed wetting since one year
according to attenders
change in behavior (talking to self) since 1.5 years
anatomical localisation of lesion
b/l ptosis-weakness of levator palbebral superioris
(without loss of frowning)
self talk-frontal lobe
vertical gaze palsy:
the centres and pathway for vertical gaze:
vertical gaze palsy is
supranuclear
nuclear
infranuclear (eg.nmj disorders)
the doll's eye manaever is used to differentiate between supra and infra
suggesting the activation of vestibulo -occular system
therefore intact doll's eye, suggests a supranuclear lesion
*. *.
b) What is the etiology of the current problem and how would you as a member of the treating team arrive at a diagnosis? Please chart out the sequence of events timeline between the manifestations of each of his problems and current outcomes.
etiology
b/l ptosis-
1)myasthenia gravis
2)3rd nerve palsy
3)horner's syndrome
4)myotonic dystrophy
5) mitochondrial myopathy
6)occuplopharyngeal muscular dystrophy
mysasthenia-no history of fluctuation/fatigueable ptosis
myotinic dystrophy-no other signs of the disease, especially on sustained contraction of the muscles
occulo pharngeal-intact bulbar cranial nerves rules this out.
self talking and altered behavior-frontal lobe of the brain.
Frequent falls
c)What is the efficacy of each of the drugs listed in his current treatment plan
efficacy of drugs
syndopa was initiated to differentiate psp from Parkinson's disease
https://www.nejm.org/doi/full/10.1056/nejmoa033447
In this randomized, double-blind, placebo-controlled trial, we evaluated 361 patients with early Parkinson's disease who were assigned to receive carbidopa–levodopa at a daily dose of 37.5 and 150 mg, 75 and 300 mg, or 150 and 600 mg, respectively, or a matching placebo for a period of 40 weeks, and then to undergo withdrawal of treatment for 2 weeks.
The severity of parkinsonism increased more in the placebo group than in all the groups receiving levodopa:
Question2
Case presentation links:
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:
progressive sob from grade 2 to 4 since 2 months
orthopnea,pnd
b/l pedal edema upto knee since 2 months
Generalised weakness since 2 months
H/o cva (rt hemiparesis recovered) with persistent loss of speech since 2 years.
anatomical localisation
based on history:pnd ,sob with orthopnea suggest left heart failure
based on examination:
shift of apex to 6th ics,presence of thrill palpable at apex(?s1), nature of the apex not mentioned
presence of ,dilated veins ,pedal edema,s3 in both apical and left parasternal areas.
(?biventricular failure)
b) What is the etiology of the current problem and how would you as a member of the treating team arrive at a diagnosis? Please chart out the sequence of events timeline between the manifestations of each of his problems and current outcomes.
etiology:
CAD
Ecg showing
1)normal axis
2)pathological Q waves from v1 to v6
3)poor R wave progression
suggest a CAD probably involving LAD and LCX territory
confirmed with finding on the echo
1)heart failure in the setting of CAD occurs due to
(MI) frequently leads to permanent death of cardiac muscle. The infarcted segment is akinetic/dyskinetic, thus leading to inadequate relaxation in diastole and impaired contraction in systole
2)subsequent remodeling of the ventricle can occur in myocardial segments that are remote from the site of infarction . Ventricular dilatation can promote annular dilation, with consequent mitral regurgitation, which can predispose to heart failure.
c) What is the efficacy of each of the drugs listed in his current treatment plan
1)salt and fluid restriction
2)benfomet as thiamine replacement in alcoholic pts
33)aldactone(spironolactone)
Q.3.52 year old male , shopkeeper by profession complains of SOB, cough ,decrease sleep and appetite since 10 days and developed severe hyponatremia soon after admission.
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 presentation:
sob grade 2 or 3?non progressive since 10 days
cough with sputum since 10 days
decreased sleep since 10 days
decreased appetite since 10 days
after admission:
drowsiness and giddiness
anatomical localisation:
sob without pedal edema, pnd, orthopnea can be localised to the lung
(sob on exertion grade 2 can also be localised the heart but no history or examination finding of pedal edema or jvp rise rules it out)
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
.
Answer..
Patient has SOB grade 2 and evaluation he has severe Anemia which lead to heart failure. And giving him Fluids which might be the cause of his hyponatremia is purely because of dilutional.
First I would have given him fluid restriction and preload reducing agents like lasix because he has heart failure and dilated ivc.
Giving him the lasix would be my main concern in him. Second thing is controlling blood sugars.
He presented with sob grade 2 and decreased sleep and generalised weakness.
On evaluation patient had Anemia which lead to heart failure and type 2 Diabetes mellitus which is poor control.
Anemia with heart'failure
⬇️
Fluids and poor control of sugars
⬇️
His symptoms worsened, sob increased and landed in hyponatremia
⬇️
Poor control of sugars continued and didn't restricted fluids.
⬇️
Hyponatremia in this case was due to two reasons, iv fluids and poor sugar Control.
⬇️
Patient developed symptoms of hyponatremia like disturbed sleep pattern, drowsy and mild altered sensorium.
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?
Answer.
There is no role in giving him monocef and metrogyl to him. Their diagnosis is not explaining the treatment.
Efficacy of vaptans over placebo
Can one give both 3% sodium as well as vaptan to the same patient?
We shouldn't give both at the same time.
4) Please mention your individual learning experiences from this month.
1.) Our unit has attempted for a USG guided ascitic tap and I participated.
2.)I myself have drained 750 ml of ascitic fluid over 2 intervals in a different case.
3.)Seen a case of Parkinsonism in its early stage in the OPD
4.)Learnt management of recurrent hypoglycemia induced by OHA and the manner to monitor such patients, and what danger signs to look out for.
5.)Seen and learnt management of a case of DKA induced by stress and irregular intake of insulin who is a known case of DM 2 since she was 12 years old.
6.)Seen and known of a case of DM type 3
7.)Seen many cases of heart failure with reduced ejection fraction
8.)Seen and learnt management of a few number of cases of shortness of breath which is due to exacerbation of COPD, and how if the patient still doesn't stop the habit of smoking, no amount of rigourous treatment can be of good effect.
9.) Seen cases of alcoholic gastritis secondary to chronic alcoholic liver disease
10.) Performed high quality CPR to a patient in ICU.
