Blended Learning Bimonthly Assignment Novemeber 2020

 

Medicine Department

Sunday, November 8, 2020

Blended learning Bimonthly assignment for November 2020

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

a) 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. 

1. Pain in the epigastric region 

It may be due to - 

A. Myocardial Infarction 

B. Acute Pancreatitis 

C. Cholecystitis 

D. Peptic Ulcer 

E. Acid Reflux Disease 

F. Gastritis 

2. Shortness of Breath 

It may be due to - 

A. Acidosis due to renal failure 

B. Pleural Effusion 

3. Decreased Urine output 

A. It may be due to renal failure 

B. Secondary to acute pancreatitis

Release of pancreatic amylase from the injured pancreas with resulting impairment of renal microcirculation, decrease in renal perfusion pressure due to abdominal compartment syndrome, intra-abdominal hypertension and hypovolemia.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6041506/

4. Abdominal distention with constipation and nausea 

This may be due to - 

Bowel complications of acute pancreatitis such as paralytic ileus, ischemic necrosis, perforation and mechanical obstruction

This is believed to stem from either:

1) severe inflammation of the body and tail of the pancreas causing extrinsic compression;

2) retroperitoneal extravasation of pancreatic enzymes causing pericolitis and/or pericolic fibrosis; 

3) thrombosis of mesenteric arteries (often associated with hypercoagulability during severe inflammatory states); or 

4) infarction/ischemic necrosis of watershed areas secondary to systemic hypotension. Retroperitoneal inflammation may also lead to the involvement of other segments of bowel including the small intestine

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5330692/

During the first 1-2 wk, a pro-inflammatory response occurs, which results in systemic inflammatory response syndrome (SIRS), a sterile response in which sepsis or infection rarely occurs. If the SIRS is severe, then proinflammatory mediators can cause early multiple (respiratory, cardiovascular, renal, and hepatic) organ failure

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4194569/

Sequence of events

1.Diaphyseal dysplasia of both tibia

2. Patient is a alcoholic and smoker since 30years

3. Patient has an atherosclerotic vascular disease of right upper limb

4. Patient presented with chest pain,sob, decreased urine output(due to AKI secondary to sepsis),constipation(due to paralytic ileus),abdominal distension

He was diagnosed with acute severe pancreatitis

5. Patient was started on inj.lasix and iv antibiotics and after 1 day pedal edema and sob decreased, the next day, patient was in altered sensorium and was taken for hemodialysis and serum creatinine decreased

 6. After 2days patient was taken for next session of dialysis

7. Within 24hrs of 2nd session of dialysis his creat increased again to 5.4 and patient had 8episodes of vomitings and was intolerant to oral feeds.

B)

1)Fluid replacement

Increased vascular permeability in acute pancreatitis causes the loss of intravenous fluid and reduces plasma volume. Hypovolemia may lead to shock and acute renal failure

2) Antibiotics

3) Analgesics - Pain is one of the symptoms of acute pancreatitis

4) Nebulization in view of B/L wheese

5)Diuretics for decreased urine output due to renal failure

Non pharmacological interventions

1)nill per mouth

2)ryles tube catheterisation for nutritional support

3)oxygenation - Patients should be monitered closely for early detection of respiratory failure

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.com/2020/11/55-year-old-male-with-anemia.html?m=1

a) 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. 

1. Kidneys

2. Bone Marrow 

3. Lungs 

Sequence of events 

1. 35 years ago alcohol started 

2. 35 years ago smoking started 

3. 4 days ago stopped smoking 

4. 4 months ago stopped alcohol 

5. 2 months ago (Fever low grade, Generalised weakness, headache, neck pain, loss of appetite, weight loss) 

6. 2 weeks ago (Cough, Shortness of breath) 

7. 2 days before admission - Vomitings, Pain abdomen 

8. Admission 

9. Diagnosed with Multiple myeloma and Pulmonary Tuberculosis. Started on ATT and refered to higher centre for oncology opinion

B)

Pharmacological interventions

1. Antibiotics 

Increased susceptibility to infections

2. Blood transfusion - Severe Anemia 

Non pharmacological

1. Pleural fluid analysis

2. Imaging -xray skull, hrct chest

3. Serum electrophoresis,sputum culture

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/2020/11/51-yr-old-male-with-hfref.html?m=1

A) 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. 

1.Diabetes and hypertension causing macrovasuclar and microvascular dysfunction

2.Heart failure with reduced ejection fraction

LVF due to hypertension

Leading to PAH

PAH causing right heart failure

3.Atrial fibrillation :heart failure ,diabetic and hypertension are also risk factors for AF.

4) Due to AF - there is formation and dislodgement of thrombus , leading to stroke in this patient.

5.seizures in this patient is again due to stroke .

(Infarct in right frontal lobe )

Sequence of Events 

1. Tobacco chewing (40 years)

2.Alcohol (10 years)

3. DM (7 years) 

4. HTN (5 years) 

5. 1st Episode GTCS (3 years) & AF with HFpEF

6. 2nd Episode GTCS (2 years)

7. HFrEF & Anasarca (1 year) - (subsided with medication)

8. Pedal edema (6 months) 

9. Increased pedal edema , abdominal distention , SOB and decreased urine output (3 days)

B)

1. Preload reducing agents - Diuretics (only if symptomatic)

2. Afterload reducing agents - vaso dilators ,ace inhibitors and arb 

3. Beta blockers for preventing cardiac remodeling and reduce mortality.

4. Antiepileptics known case of epilepsy)

5. Insulin for glycemic control in diabetes.

Non pharmacological interventions

1. Salt and fluid restriction

Individualized salt and fluid restriction can improve signs and symptoms of CHF 

4) 31 yr old man with B/L pedal edema with scrotal and penile swelling since 2 months

https://nairaditya97.blogspot.com/2020/11/31-yr-old-male-with-bl-pedal-edema-with.html?m=1

a) 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. 

1. Heart 

EVENTS TIME LINE:

1. Alcohol & khaini (3 years) 

2. Pins and needles (1 year) 

3. Palpitations (8 months) 

4. PND (3 months) 

5. Pedal edema and SOB (2 months)

B) 

Pharmacological interventions

1. Diuretics

2. Thiamine

Non pharmacological interventions

Salt and fluid restriction