Bimonthly assessment

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

Question 1) pain in the epigastric region differentials

Epigastric	Biliary: cholecystitis, cholelithiasis, cholangitis
	Cardiac: myocardial infarction, pericarditis
	Gastric: esophagitis, gastritis, peptic ulcer
	Pancreatic: mass, pancreatitis
	Vascular: aortic dissection, mesenteric ischemia p971.html

Gall stones :

This occurs at the level of the sphincter of Oddi, a round muscle located at the opening of the bile duct into the small intestine. If a stone from the gallbladder should travel down the common bile duct and get stuck at the sphincter, it blocks outflow of all material from the liver and pancreas. This results in inflammation of the pancreas that can be quite severe.

2)sob- acidosis due to renal failure

         ? Ards secondary to sepsis/pancreatitis

          Pleural effusion due to acute pancreatitis

          

3)decreased urine output-pre renal Aki secondary to volume loss(oliguric)

3rd space loss due to pancreatitis

Sepsis induced aki

4) abdominal distention with constipation and nausea

Secondary to paralytic ileus

2) pharmacological interventions

1)fluid replacement

Increased vascular permeability in acute pancreatitis causes the loss of intravenous fluid and reduces plasma volume. In severe cases, in patients with massive ascites, pleural effusion, and retroperitoneal and mesenteric edema, circulating plasma volume decreases markedly. Hypovolemia may lead to shock and acute renal failure, and, because hypovolemic shock may impair the pancreatic microcirculation and promote pancreatic ischemia and necrosis, restoration and maintenance of plasma volume is crucial in severe acute pancreatitis.

2) antibiotics

On the other hand, a placebo-controlled, double-blind trial of ciprofloxacin  +  metronidazole in patients with predicted severe acute pancreatitis showed that prophylactic administration of these antibiotics did not prevent pancreatic infection (Level 1b).

3)analgesics

4) nebulization in view of b/l wheeze secondary to ?copd

5)diuretics for decreased urine output due to renal failure

Non pharmacological interventions

1)nill per mouth

2)ryles tube catheterisation

3)oxygenation

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. 

ANATOMICAL LOCATIONS WITH ETIOLOGY:

BONE MARROW

Etiology: Multiple myeloma

KIDNEYS

Etiology: AKI due to multiple myeloma

HEMATOLOGICAL (ANEMIA)

Etiology: secondary to multiple myeloma

LUNGS

Etiology: Tuberculosis (Increased susceptibility to infections)

TIMELINE OF EVENTS:

Alcohol & smoking (35 years) 

Stopped alcohol (4 years)

Fever , generalised weakness & anemia - 2 units blood transfusion (1.5 years)

Stopped smoking (4 months)

Low grade fever , generalized weakness , headache , neck pain , loss of appetite , weight loss (2 months) 

Cough & SOB (2 weeks) 

Vomiting & pain abdomen (2 days)

OUTCOME:

Some symptomatic relief and referred to higher centre in need for oncologist

B) 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? 

PHARMACOLOGIC :

1.ANTIBIOTICS : For underlying infection (Azithromycin for ?Atypical pneumonia)

2.ATT : For TB

3.SEVELAMER : For hyperphosphatemia

4.FEBUXOSTAT : For hyperuricemia

5.PRBC transfusion for anemia

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)pedal edema with abdominal distention with sob suggestive of right heart failure or renal failure

B)etilogy of rt heart failure

chronic conditions of pressure overload may lead to RVF. These include:

• Primary pulmonary arterial hypertension (PAH) and secondary pulmonary hypertension (PH) as seen in chronic-obstructive pulmonary disease (COPD) or pulmonary fibrosis)

• Congenital heart disease (pulmonic stenosis, right ventricular outflow tract obstruction, or a systemic RV).

The following conditions result in volume overload causing RVF:

• Valvular insufficiency (tricuspid or pulmonic) 

• Congenital heart disease with a shunt (atrial septal defect (ASD) or anomalous pulmonary venous return (APVR)).

Another important mechanism that leads to RVF is intrinsic RV myocardial disease. This includes:

• RV ischemia or infarct

• Infiltrative diseases such as amyloidosis or sarcoidosis

• Arrhythmogenic right ventricular dysplasia (ARVD)

• Cardiomyopathy

• Microvascular disease.

Lastly, RVF may be caused by impaired filling which is seen in the following conditions:

• Constrictive pericarditis

• Tricuspid stenosis

• Systemic vasodilatory shock

• Cardiac tamponade

• Superior vena cava syndrome

• Hypovolemia. 
• B) 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? 

)Pharmacological interventions

(meta analysis with each class of drugs)

Preload reducers

Diuretics

Afterload reducers-ace inhibitors

Rate controlling agents-beta blockers

Antiepileptics for known case of epilepsy

Insulin for glycemic control in diabetes.

Non pharmacological interventions

Salt and fluid restriction

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

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. 

ANATOMICAL LOCATIONS WITH ETIOLOGY:

HEART FAILURE (pedal edema , penile & scrotal swelling and SOB) :

Etiology: Alcohol causing wet beriberi

AXONAL SENSORY POLYNEUROPATHY:

Etiology: Alcohol

EVENTS TIME LINE:

Alcohol & khaini (3 years) 

Pins and needles (1 year) 

Palpitations (8 months) 

PND (3 months) 

Pedal edema and SOB (2 months)

CURRENT OUTCOME: 

Completly relieved of his symptoms as the wet beriberi resolved.

B) What are the pharmacological and non pharmacological interventions used in the management of this patient and what are the efficacy of each one of 

pharmacological interventions

Diuretics

Thiamine

2)non pharmacological interventions

Salt and fluid restriction